小兒血液相關疾病

及血球型態的探討

中國醫藥大學附設醫院

兒童醫學中心

巫康熙 助理教授醫師

PART I 小兒常見血球型態

PART II 小兒常見血液疾病

PART III 小兒血液專科考題

PART I

小兒常見血球型態

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

PART I 小兒常見血球型態

PART II 小兒常見血液疾病

PART III 小兒血液專科考題

PART I

小兒常見血球型態

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

PART I

小兒常見血球型態

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smear

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smear RBC morphology

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

On smear how to evaluate the sizes of RBCs Compared with small lymphocytes

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Elliptocytes (ovalocytes) IDA

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Basophilic stippling lead poison thalassemia

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Polychromatic RBC (reticulocytes) hemolytic anemia

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Megalocytes megaloblastic anemia

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Howell-Jolly bodies splenectomy

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Target cells IDA thalassemia

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acanthocytes

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Sickle cells

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Schizocytes fragmentocytes microangiopathic hemolytic anemia

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smear

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Neutrophilic myelocytes metamyelocytes band and segmented from

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Atypical lymphocyte

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

lymphoblasts

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Myeloblasts

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia M3 subtype

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smear

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Giant platelet

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood smearRBC

Anisocytosis vs Poikilocytosis Spherocytes hereditary spherocytosis immune hemolytic anemia Target cells hemoglobinopathy thalassemia iron deficiency anemia Hypochromic RBC thalassemia iron deficiency anemia Fragmented RBC (microangiopathy) hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura DIC Bite cellsblister cells G6PD deficiency Polychromatophilia (reticulocytes) RBC loss or destruction Nucleated RBC severe RBC loss or destructionWBC Blast cells leukemia Neutrophil hypersegmentation folate deficiency vitamin B12 deficiency Atypical lymphocytes viral infectionPlateletadequate increase decrease

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

PART II

小兒常見血液疾病

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

血液主要成份

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

HSCs

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

血液病的診斷

應從病史理學檢查及實驗檢查三方面加以鑑別

診斷才能正確找出病因妥善給予治療

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

The anemias

Anemia defined

a reduction of the red blood cell volume or

hemoglobin concentration below the range of values

occurring in healthy persons

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

80140-180Male

80120-160Female

Adult

76-80110-1607-12 yr

70-74105-1406 mo-6 yr

95-1453 mo

130-2002 wk

110137-201Cord blood

LowestRangeAge

MCVHemoglobin

Hemoglobin and MCV during children

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

貧血的分類紅血球製造不足

(1) 骨髓衰竭再生不良性貧血

(2) 紅血球生成素分泌不足如慢性腎衰竭甲狀腺功

能低下症慢性發炎及營養不良等

紅血球成熟不良及造血失敗

(1) 細胞質成熟不良缺鐵性貧血海洋性貧血

(2) 細胞核成熟不良如維他命B12及葉酸缺乏等

溶血性貧血

(1) 血紅素缺陷海洋性貧血

(2) 紅血球細胞膜缺陷如遺傳性球狀紅血球症等

(3) 紅血球代謝缺陷如G6PD缺乏症(蠶豆症)

(4) 抗體引發者

急性失血

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Hemolytic anemiasDefinitions of Hemolytic Anemias

Hemolysis is defined as the premature destruction of red blood cells If the rate of destruction exceeds the capacity of the marrow toproduce RBCs anemia resultsNormal RBC survival time is 110ndash120 days and approximately 1 of RBCs are removed each day and replaced by the marrow to maintain the RBC count During hemolysis RBC survival is shortened and increased marrow activity results in a heightened reticulocyte percentage and number

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

The classification of hemolytic anemias

Cellular resulting from intrinsic abnormalities of the membrane enzymes or hemoglobin (most of the cellular defects are inherited)

Extracellular resulting from antibodies mechanical factors or plasma factors (most of the extracellular defects are acquired)

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Hemolytic anemiaElevations of serum unconjugated bilirubin also may accompany hemolysis Hemoglobin binds to haptoglobin and hemopexin both of which are cleared more rapidly as conjugates and their plasma concentration is decreased When the renal tubular reabsorptive capacity of the kidneys for hemoglobin is exceeded free hemoglobin appears in the urine- hemoglobinuriaGallstones composed of calcium bilirubinate may be formed in children with chronic hemolysis

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Polychromatic RBC (reticulocytes) hemolytic anemia

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Nucleated RBCs very young RBCs

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Normal RBCsWhat do you find

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you finding

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Hemoglobin disordersThe hemoglobin genes result in structural changes in the hemoglobin molecule leading to a change in function

Qualitative abnormalies (hemoglobinopathies structural abnormalities ie sickle hemoglobins)

Quantitative abnormalities (abnormal hemoglobin production ie thalassemias)

The hemoglobinopathies

There are approximately 700 variant hemoglobins

Hemoglobinopathies hemoglobin C hemoglobin E

hemoglobin D

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Thalassemias

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

海洋性貧血流行分佈地區

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

海洋性貧血的分類及發生率

1 α型(甲型)海洋性貧血

台灣約佔全人口 4

2 β型(乙型)海洋性貧血

台灣約暫全人口 2

3 其他型海洋性貧血

台灣少見

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

何謂輕型重型海洋性貧血

輕型帶海洋性貧血的基因輕微貧血對生活

沒有影響不需治療

重型由父母雙方遺傳到同型的海洋性(βo βo)

貧血嚴重貧血需定期輸血及排鐵治療

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Pathophysiology of thalassemia

Molecular pathology β-thalassemia point mutation IVS 2nt 654

Codon 4141 -28 Codon 17 -32 α-thalassemia genes deletion

South-east Asian Thailand Mediterranean

Cellular pathology ineffective erythropoiesis and hemolysis

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

海洋性貧血的遺傳方式 (一)

AA AA AA AA AA AA Aa Aa

AA x AA Aa x AA

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

海洋性貧血的遺傳方式 (二)

AA Aa Aa aa Aa Aa Aa Aa

Aa x Aa aa x AA

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

DiagnosisFamily history

CBC Hb darr MCVdarr MCH darr

PB smear microcytic hypochromic anisopoikylocytosis basophilic stippling target cell elliptocyte

Hb electrophoresis

Rule out other diseases serum ironTIBC ferritin

Molecular diagnosis

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Normal RBC What do you find

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Normal RBCsWhat do you find

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Iron deficiency anemia (IDA)The age is important clue for diagnosis of IDA

Infants breast-fed exclusively should receive iron supplementation from 4 mo of age Adolescents are also susceptible to iron deficiency because of high requirements due to the growth spurt dietary deficiencies and menstrual blood loss

Iron deficiency (even iron deficiency without significant anemia) may have effects on neurologic and intellectual function

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Etiology of IDAIn term infants anemia caused solely by inadequate dietary iron is unusual before 6 mo and usually occurs at 9ndash24 mo of ageBlood loss must be considered in IDA Gastrointestinal tract peptic ulcer

Meckel diverticulum polyp hemangioma chronic diarrhea inflammatory bowel disease Hookworm

Pulmonary hemosiderosis Menstrual blood loss

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Laboratory findingsIn progressive iron deficiency a sequence of biochemical and hematologic events occurs

First the tissue iron stores represented by bone marrow hemosiderin disappearThe level of serum ferritin decreasesNext serum iron level decreases total iron-binding capacity of the serum (TIBC serum transferrin) increases percent saturation (transferrin saturation serum ironTIBC) falls below normal

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Differential diagnosis

Iron deficiency must be differentiated from other hypochromic microcytic anemias

Thalassemia trait

The anemia of chronic disease and infection

Lead poisoning

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

TreatmentThe regular response of IDA to adequate amounts of iron is an important diagnostic and therapeutic featureOral administration of simple ferrous salts A daily total of 4ndash 6thinspmgkg While adequate iron medication is given the family must be educated about the patients diet and the consumption of milk

should be limited Iron medication should be continued for 8 wk afterblood values are normal

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Enzymatic defectsVarious red blood cell enzymatic defects produce hemolytic anemias

Deficiencies of most of the enzymes in both the anaerobic Embden-Meyerhof pathway and the oxidative hexose monophosphate (pentose) shunt have been described

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Glucose-6-phosphate dehydrogenase(G6PD) deficiency

G6PD deficiency is the most important disease of the hexose monophosphate pathway

This X-linked enzyme deficiency

The deficiency is caused by inheritance of any of a large number of abnormal alleles of the gene responsible for the synthesis of the G6PD molecule

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

性聯遺傳

XYX XO

XXO XX XOY XY

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Clinical manifestationsIn some patients ingestion of fava beans may also produce an acute and severe hemolytic syndrome called favism

Infection also may result in hemolysis

Acute hemolysis jaundice hemoglobinuria (tea-color urine) result and the hemoglobin may fall precipitously reticulocytosis

In Chinese newborns with the Canton varieties the deficiency of G6PD is an important cause of hyperbilirubinemia of newborn

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

黃疸

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

normalsevere

Hemoglobinuria (tea colored urine) G6PD deficiency with acute hemolysis

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Diagnosis prevention and treatmentThe diagnosis depends on direct or indirect demonstration of reduced G6PD activity in RBCs

Prevention of hemolysis constitutes the most important therapeutic measure

New born screen for G6PD deficiency in Taiwan

When hemolysis has occurred supportive therapy may require blood transfusions although recovery is the rule when the oxidant agent is removed

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

spherocyte

normal RBC

reticulocyte

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Immune hemolytic anemiasThe hallmark of this group of diseases is a positive direct antiglobulin (Coombs) test which detects a coating of immunoglobulin or components of complement on the RBC surface

Hemolytic disease of the newborn caused by transplacental transfer of maternal antibody active against the RBCs of the fetus that is isoimmunehemolytic anemia

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Etiology of autoimmune hemolytic anemia

Idiopathic Infections (Epstein-Barr virus rarely HIV cytomegalovirus and Mycoplasma)Immunologic diseases (systemic lupus erythematosus rheumatoid arthritis)Immunodeficiency diseases (agammaglobulinemia) Neoplasms (lymphoma leukemia) Drugs (methyldopa levodopa)

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Laboratory findingsAnemia leukocytosis is common and platelet count is usually normal

Spherocytosis polychromasia and nucleated RBCsare present

Direct antiglobulin test (direct Coombs test) are strongly positive and free antibody can sometimes be demonstrated in the serum (indirect Coombs test)

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

TreatmentTransfusions usually are only of transient benefit It may be difficult to find compatible bloodGlucocorticoidsIntravenous immunoglobulin DanazolSplenectomyImmunosuppressive agents Various plasmapheresis

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

spherocyte

normal RBC

reticulocyte

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Hereditary SpherocytosisThe most common abnormality of the red blood cell membrane Hereditary spherocytosis usually is transmitted as an autosomal dominant and As many as 25 of patients have no previous family history May present as anemia and hyperbilirubinemia in newbornAfter infancy the spleen is usually enlarged and pigmentary(bilirubin) gallstones may formReticulocytosis and indirect hyperbilirubinemia The RBCs on the blood film reticulocytosis and spherocytesWhether all patients with hereditary spherocytosis should undergo splenectomy is controversial

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

fragmented RBC

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Microangiopathic hemolytic anemia

Red blood cell destruction because of mechanical

injury as the cells traverse a damaged vascular bed

When RBCs are sheared by fibrin in the capillaries

fragmented RBCs (schistocytes)

Common diseases hemolytic-uremic syndrome

thrombotic thrombocytopenic purpura or DIC

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

DDx of thrombocytopenia1 Impaired or ineffective production

bone marrow replacement disease bone marrowaplasia

2 Destructive thrombocytopenias Immune-Mediated

ITP infection autoimmune lymphoproliferativedisorders alloimmune

Nonimmune-MediatedDIC hemolytic-uremic syndrome TTP Kasabach-Merritt syndrome

3 Sequestration hypersplenism

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Pseudothrombopenia result from the autoaggutination o platelets(platelet aggregate)

or adherence of platelets to neutrophils or monocytest(satellitism)

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Idiopathic (immune) thrombocytopenic purpura （ITP）

A rather common blood disease in childrenA self-limited disease usually

Classification of ITPAcute run a self-limited short courseChronic clinical course more than 6 months usually unresponsive to the treatment

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Suggested mechanisms of childhood ITP

Genetics

Anti-platelet antibody antibody-coated platelets were cleared by reticulo-endothelial system

immune complex

modulation of platelet membrane

Cytokine dysregulation

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

The pathogenesis of thrombocytopenia in ITP

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Clinical manifestation of childhood ITP

Petechia and ecchymosis of skin most common

Mucosal bleeding (nasaloral and sub-

conjunctival) 30-40

G-I G-U or menorrhagia

Intra-cranial hemorrhage1

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Diagnosis of ITP 1 History 2 Physical examination3 Laboratory

CBC and WBC classification usually normal hemoglobin and normal WBC

Peripheral blood smear no blast cells giant platelets Bone marrow examination megakaryocytes increase to rule

out other diseases resulting in thrombocytopenia eg leukemia aplastic anemia amegakaryocyticthrombocytopenia

Others ANA HIV anti-platelet antibodies Coombs test4 Rule out other problems resulting in thrombocytopenia

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Treatment of ITP 1 Supportive treatment

2 Corticosteroid

3 High-dose IVIG

4 IV anti-D therapy

5 Splenetomy

6 Platelet transfusion only if life

threatening bleeding

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

The pancytopeniasAnemia neutropenia and thrombocytopeniaPancytopenia can result from (1) failure of production of hematopoietic

progenitors destruction (eg aplastic anemia)

(2) replacement of the bone marrow by tumor (3) dysplasiafibrosis Pancytopenia can be constitutional (inherited genetic) or be acquired

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Definition of aplastic anemiaThe hallmark of aplastic anemia is peripheral pancytopenia coupled with hypoplastic or aplasticbone marrow Severe aplastic anemia (SAA) is defined Two or more cell components compromised1 absolute neutrophil count lt 500mm3 2 platelet count lt 20000mm3 3 reticulocyte count lt 1 after correction

Bone marrow biopsy material hypocellular

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Hypocellularity in bone marrow biopsy

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Bone marrow aplasia aplastic anemia

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Treatment of aplastic anemiaComprehensive supportive care Immunosuppression ATG cyclosporinehematopoietic colony-stimulating factor Hematopoietic stem cell transplantation HLA identical sibling marrow donor

90 chance of long-term survival Matched unrelated donor transplantation Othrs androgens corticosteroids high-dosecyclophosphamide and plasmapheresis

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

急性淋巴性白血病小文是個4歲的男孩但最近一個月來臉色愈來

愈蒼白輕輕碰撞身上就出現瘀青食慾減退

有時也容易發燒

媽媽於是帶他去看小兒科醫師醫師注意到他已貧

血及肝脾腫大的現象就請小文去抽血結果發現

嚴重貧血血紅素質只有5gdl (正常4歲小孩血紅素

值應大於14~45萬mm3)白血球數目4萬3千mm3

白血球(白血球正常值4千~1萬mm3)而且不正常

的血癌細胞佔了白血球總數的94

檢查結果小文罹患了急性淋巴性白血病必須接受

2年半的化學治療

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

The leukemiasThe most common malignancy in childhood (about 30-40 of childhood cancers)Malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to a clonal proliferation of cellsThe progeny of these cells have a growth advantage over normal cellular elements owing to an increase rate of proliferation a decreased rate of spontaneous apoptosis or bothThis result is a disruption of normal marrow function and ultimately marrow failure

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

HSCs

Blasts

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Classification in leukemiaAcuterapid onset short course if untreated immature cell dominant Chronicslow onset long course if untreated mature cell dominant Predominant cell types myeloid vs lymphoid

Clinical Form

1 Acute lymphoblastic leukemia (ALL) 75-80 of childhood leukemia

2 Acute myeloid (myelogenous) leukemia (AMLANLL) more common in adults

3 (adult-type) Chronic myeloid leukemia (CML) rare in childrenJuvenile Chronic myelomonocytic leukemia (JMML) rare

4 Chronic lymphoblastic leukemia (CLL) rarely seen lt30yo

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Signs amp symptoms in acute leukemiaTumor cells infiltrate in bone marrow Anemia pallor weakness Thrombocytopenia bleeding petechiaecchymosis Granulocytopenia fever infectionsLeukemia infiltrate LymphadenopathyHepatosplenomegalyBonejoint pain (multiple large joints migratory) CNSheadache vomiting cranial nervesMediastinal mass Testicular enlargementSoft tissue Fever rapid tumor cell turn-over infection

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Diagnosis of leukemiaSymptoms and signsPE lymphadenopathy hepatosplenomegalyhellipLab CBC anemia thrombocytopennia leukopenia

or leukocytosis Peripheral blood smear leukemic cells

(mimicking as atypical lymphocytes or lymphocytes)

Bone marrow aspirationbiopsy morphology immunophenotyping karyotype

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Diagnosis in leukemia 1 MorphologyCytochemistry (FAB Classification)

2 Immunophenotyping (cell marker)

3 Cytogeneticskaryotype (chromosome study)

4 Molecular biology

Fuorescent in situ hybridization (FISH)

Polymerase chain reaction (PCR) oncogene

DNA microarray

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

白血病的型態分類

常是偶然抽血才發現白血球數極高若不治療會轉變成急性白血病而死亡

成人型

很少見預後極差幼年型髓性白血病慢

性骨

M0未分化

M1骨髓母細胞無成熟現象

M2骨髓母細胞有成熟現象

M3前骨髓細胞

M4骨髓及單核球細胞

M5單核球細胞

M6紅血球母細胞

M7巨核細胞

急性骨髓性白血病

L1最常見占80L2L3占1~2

急性淋巴性白血球

急性白血病

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

MorphologyCytochemistry (FAB Classification)

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute lymphoblastic leukemia (L1 type)

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute lymphoblastic leukemia (L1 or L2 type)

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute lymphoblastic leukemia (L3 type)

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Immunologic classification of ALL

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Common Chromosomal Abnormalities in the Acute Leukemias of Childhood

Favorableinv(16)AML M4

Favorablet(1517)AML M3

Favorablet(821)AML M2

UnfavorablehypodiploidyALL (general)

FavorablehyperdiploidyALL (general)

Nonet(814)ALL B-cell

Unfavorablet(922)ALL pre-B

Unfavorablet411)ALL pre-B (infantile)

Favorablet(1221)ALL pre-B

Influence on PrognosisChromosomal AbnormalityDisease Subtype

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Survival rates of children with ALL

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid (myelogenous) leukemia

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M0 M1 M2 M3)

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M3)

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M4)

NSE stain

MPO stain

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M5)

NSE stain

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M6)

PAS stain

Cell marker glycophorin A

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Acute myeloid leukemia (M7)

Cell marker CD41CD61

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Peripheral blood finding in CML1 Blood picture in CML often contributes more to the diagnosis

than the bone marrow2 Besides the high leukocyte count and a pathologic left shift with

the appearance of immature granulocytopoietic forms at allstages(including procyelocytes and myeloblasts) eosinophiliaand basophilia are present in the peripheral blood andcorroborate the diagnosis

3 Individual granulocytes show qualitative changes such asanisocytosis nuclear-cytoplasmic asynchrony andhyposegmentation(pseudo-pelger forms)

4 These changes are largely absent during the eraly chronic phase5 The same changes may be found in severe reactive leukocytoses

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

PB smear in CML

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Criteria for the diagnosis of JMML

European Working Group of MDS in Childhood Blood 1998 91 365

5 GM-CSF hypersensitivity of myeloid progenitors

4 Clonal abnormality (including monosomy 7)

3 White blood count gt 10 x 109L(at least 2)

2 Myeloid precursors on peripheral blood smeardefinite diagnosis

1 Hemoglobin F increased for ageCriteria requested for

3 Bone marrow blasts lt 20

2 Peripheral blood monocyte count gt 1 x 109L(all 3 have to be fullfilled)

1 No Ph chromosome no bcr-abl rearrangementMinimal laboratory criteria

5 Skin rash (36)

4 Fever (54)

3 Pallor (64)

2 Lymphadenopathy (76)

1 Hepatosplenomegaly (97)Suggestive clinical features

ItemCategory

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

PART III

小兒血液專科考題

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 1A 5 year-old girl was found pale looking and petechia for 2 weeksPE generalized ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow biopsy1C What is your tentative diagnosis1D How to treat this patient4

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

What do you find

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 1B Bone marrow biopsy

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 2A 2 year-old boy was found pale looking for 2 months mother Vietnamese(越南人) father TaiwanesePE hepatosplenomegalyLaboratory dataWBC 874 x 103ul Hb 48 gmdl MCV 65 fL Platelet count 256 x103ul Hemoglobin electrophoresis HbA 114 HbA2 23 Hb E 464 Hb F 399 Serum ferritin 98 ngmL

Please describe the below findings 2A Peripheral blood smear2B Bone marrow examination2C What is your tentative diagnosis How to confirm your diagnosis2D How to treat this patient

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 2A Peripheral blood smear

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 2B Bone marrow finding

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 3A 14 year-old girl was found pale looking for 1 weekPE jaundiceLaboratory dataWBC 1174 x 103ul Hb 48 gmdl MCV 105 fL Reticulocyte 25 Platelet count 256 x103ul Total Bilirubin 68mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 3A Peripheral blood smear3B Bone marrow examination3C What is your tentative diagnosis

How to confirm your diagnosis

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 3A peripheral blood smear

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 3B Bone marrow finding

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4A 15 year-old girl was found fever for 2 weeksPE gum hypertrophy hepatosplenomegalyLaboratory dataWBC 8174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C Nonspecific esterase stain4D What is your tentative diagnosis

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4A peripheral blood smear

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4B bone marrow finding

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 5A 2yo girl was found abdomen distension and pale looking for 3 monthsPE splenomgalyLaboratory dataWBC 174 x 103ul Hb 78 gmdl Reticulocyte 05 Platelet count 56 x103ul

Please describe the below findings 5A Bone marrow finding5B What is your tentative diagnosis5C How to confirm your diagnosis

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 5A Bone marrow finding

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 1A 3 yo boy was found fever for one monthPE jaundice hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul Hb 68 gmdl Platelet count 86 x103ul Biochemistry Total Bilirubin 68mgdl Direct-Bilirubin 36 mgdl SGPT(ALT) 291 IUL SGOT(AST) 258 IUL LDH 1160 UL Creatinine 05 mgdl Cholesterol Total 275 mgdl Triglyceride(TG) 434 mgdl

Please describe the below findings 1A Peripheral blood smear1B Bone marrow examination1C What is your tentative diagnosis1D What are the possible underling problems1E How to treat this patient

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 1A Peripheral blood smear

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 1B Bone marrow examination

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 2A 5 yo girl was found pale looking and petechia for 2 weeksPE ecchymosis no lymphadenopathy no hepatosplenomegalyLaboratory dataCBC WBC 174 x 103ul (neutophil 2 lymphocyte 95) Hb 48 gmdl Reticulocyte 05 Platelet count 16 x103ul Biochemistry SGPT(ALT) 21 IUL SGOT(AST) 18 IUL LDH160 UL Creatinine 05 mgdl

Please describe the below findings 2A Peripheral blood smear2B Bone marrow biopsy2C What is your tentative diagnosis2D How to treat this patient

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4A 13yo boy was found fever for 2 weeksPE severe ecchymosis hepatosplenomegalyLaboratory dataWBC 174 x 103ul Hb 68 gmdl Platelet count 56 x103ul LDH 1256 UL PT 35sec aPTT 105sec CD13 83 CD3375

Please describe the below findings 4A Peripheral blood smear4B Bone marrow examination4C What is your tentative diagnosis4D What is the abnormal chromosome that you expect to

find in this patient

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4A peripheral blood smear

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 4B Bone marrow finding

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

Question 5A 5yo boy was found pale looking and jaundice for 2 daysPE jaundiceLaboratory dataWBC 874 x 103ul Hb 65 gmdl MCV 102 fL Reticulocyte 28 Platelet count 456 x103ul Total Bilirubin 58mgdl Direct-Bilirubin 05 mgdl

Please describe the below findings 5 A Peripheral blood smear 5 B What is your tentative diagnosis5 C How to treat this patient

5A peripheral blood smear

Thank you for your attention

5A peripheral blood smear

Thank you for your attention

Thank you for your attention