leukocytes

NeutrophilEosinophil

BasophilMonocyte

Lymphocyte

LABORATORY TESTS

WBC count

WBC differential counting Relative count, Absolute count, Schilling’s method Neutro, Eosi, Baso, Mono, Lympho

Special stains

Enzymatic determination

LEUKOPOIESIS

CFU-GM

CFU-G

Myeloblast

Promyelocyte

Neutrophilic Myelocyte

Neutrophilic Metamyelocyte

Neutrohilic Band

Neutrophil

LEUKOPOIESIS

CFU-GM

CFU-M

Monoblast

Promonocyte

Monocyte

Macrophage

LEUKOPOIESIS

CFU-Eo

Myeloblast

Eosinophilic Myelocyte

Eosinophilic Metamyelocyte

Eosinophilic Band

Eosinophil

LEUKOPOIESIS

CFU-Baso

Myeloblast

Basophilic Myelocyte

Basophil

LEUKOPOIESIS

Precursor T/NK cell

Pro-T cell Pro-NK cell

Pre-T cell

T cell NK cell

LEUKOPOIESIS

Precursor B cell

Pro-B cell

Pre-B cell

B cell

Plasma Cell

LEUKOCYTIC DISORDERS

Non-neoplastic alterations

Neoplastic Disorders Primarily Involving

Leukocytes

PURPOSE OF THE STUDY

Help in establishing diagnosis e.g. Leukemia, acute appendicitis, IM

Help in establishing prognosis e.g. leukocytosis in Px w/ pneumonia or appendicitis is a

GOOD prognosis e.g. monocytosis in Px w/ tuberculosis is a POOR prognosis

Helpful in following the course of disease

toxic effects of chemotherapy is recognized and monitored thru WBC examination

Non-Malignant Changes of White Blood Cells

Quantitative (changes in numbers)

Qualitative (morphologic alterations)

Quantitative changes of WBC

Includes: the total WBC count and; the relative & absolute concentrations of the diff’t WBC

Definitions: Leukopenia:

decrease in lymphocytes, segmenters or all cell types

Leukocytosis: increase in one or more cell types

Relative vs. Absolute Values Relative percentage of each WBC

differential count

Absolute value gives the actual number of each WBC/L Calculation: Absolute count =Total WBC count x Percent

(as a decimal)

Definition Examples: relative neutrophilia, relative and absolute lymphocytopenia

Absolute WBC & Diff’l count

AGE TOTAL WBC

NEUTRO EOSI BASO LYMPHO MONO

12 months 6.0 – 17.5

x 109/L

1.5 – 8.5

x 109/L

0.05 – 0.70

x 109/L

0 – 0.20

x 109/L

4.0 – 10.5

x 109/L

0.05 – 1.1

x 109/L

4 years 5.5 – 15.5

x 109/L

1.5 – 8.5

x 109/L

0.02 – 0.65

x 109/L

0 – 0.20

x 109/L

2.0 – 8.0

x 109/L

0 – 0.8

x 109/L

6 years 5.0 – 14.5

x 109/L

1.5 – 8.0

x 109/L

0 – 0.65

x 109/L

0 – 0.20

x 109/L

1.5 – 7.0

x 109/L

0 – 0.8

x 109/L

10 years 4.5 – 13.5

x 109/L

1.8 – 8.0

x 109/L

0 – 0.60

x 109/L

0 – 0.20

x 109/L

1.5 – 6.5

x 109/L

0 – 0.8

x 109/L

21 years 4.5 – 11.0

x 109/L

1.8 – 7.7

x 109/L

0 – 0.45

x 109/L

0 – 0.20

x 109/L

1.0 – 4.8

x 109/L

0 – 0.8

x 109/L

Qualitative Changes in WBC

Cytoplasm altered primary granules ribosomal RNA in rows lysosomal alteration vacuolation; degranulation

Nucleus pyknotic: shrunken, dense, dehydrated hypersegmented: more than 5 segments

(megaloblastic anemia)

Quantitative alteration

Changes in number

Quantitative changes in WBC GANULOCYTES

Neutrophilia: Neutropenia: Eosinophilia: Eosinopenia: Basophilia: Basopenia:

AGRANULOCYTES Monocytosis: Monocytopenia: Lymphocytosis: Lymphocytopenia: Plasmacytosis:

NEUTROPHILIA absolute ct. of neutro above normal for age absolute count >7,000/mL

FACTORS AFFECTING COUNT rate of inflow of cells from BM proportion of MGP and CGP rate of outflow of cells from blood

NEUTROPHILIA

PHYSIOLOGIC CAUSES do NOT involve tissue damage NOT related to underlying tissue pathology

Hypoxia Severe exercise, stress (crying) After eating Injection of epinephrine Heat, cold Pain, fear, anger

NEUTROPHILIA

PATHOLOGIC CAUSES occurs as a result of disease or tissue damage

Tissue Destruction/Necrosis: Myocardial Infarction, burns, surgical operations, crush

Infection: Appendicitis, salphingitis, otitis media

Hemolysis: acute and delayed HTR

NEUTROPHILIA

Toxins: Metabolic (uremia, eclampsia, gout, diabetic acidosis) Drugs/Chemicals:

(lead, mercury, potassium chlorate, turpentine, benzene)

Hemorrhage: bleeding occurred in serous cavity

NEUTROPENIA absolute count < 1,800/mL agranulocytosis: decreased prod, increased

destruction

CAUSES Myeloid hypoplasia Ineffective granulocytopoiesis Decreased survival Combination Pseudoneutropenia

NEUTROPENIA

Myeloid hypoplasia: Kostmann’s infantile genetic

agranulocytopoiesis rare, autosomal recessive w/c appears in early infancy BM shows (+) granulocytes but few maturing forms

Familial & Cyclic neutropenia autosomal dominant condition due to periodic stem cell failure lasts for 21 days

NEUTROPENIA

Lymphocytic disorder X – linked agammaglobulinemia

Myelophthisic neutropenia BM is damaged due to metastatic carcinoma or

Gaucher’s dse

Drugs Alkylating agents, ionizing radiation, chloramphenicol,

benzene, sulfonamides, quinine, quinidine

NEUTROPENIA

Ineffective Granulocytopoiesis: Chédiak – Higashi syndrome Megaloblastic anemia Myeloproliferative disorder Exposure to drugs

Decreased survival: Infections Splenic selective removal Felty’s syndrome Drug - induced

NEUTROPENIA

Combination of hypoplasia, ineffective production & decreased survival of neutrophils:

Psedoneutropenia: Endotoxin Drug induced

anesthesia ether pentobarbital

EOSINOPHILIA eosinophil count exceed 0.35 x 109/L

hypersensitive disorders release granules content that acts as anti-histamine

parasitic infections eosinophils release granule content w/c damages

the target organism

EOSINOPHILIA

CAUSES Allergic diseases:

bronchial asthma, rhinitis, hay fever mediated by IgE mast cells & basophils degranulation w/ the release of chemotactic factor

skin disorders: atopic dermatitis eczema (red & itching; [+] scaly patches that may leak fluid) pemphigus (cxd by large blisters on the skin & mucous membranes) acute urticarial reactions (hives)

EOSINOPHILIA

parasitic infestations: trichinosis tapeworm infection visceral larva migrans creeping eruption

Infectious diseases: scarlet fever (cutaneous rash) Chorea (jerky spasmodic movements of limbs, trunk, & facial muscle)

EOSINOPHILIA

Loeffler’s syndrome cxd by repeated, transient pulmonary exudates

accompanied by cough sputum contains eosinophils

PIE syndrome pulmonary infiltration w/ Eosinophilia chronic and relapsing fever, cough, dyspnea

EOSINOPHILIA

Tropical Pulmonary Eosinophilia syndrome of paroxysmal cough and bronchospasm hyperimmune reaction [very high IgE]

Hypereosinophilic syndrome: NO known cause heart, endocardial & myocardial fibrosis

EOSINOPHILIA

Splenectomy:

Drugs: Pilocarpine, physostigmine, digitalis, p-aminosalicylic acid, sulfonamides

EOSINOPENIA count is lower than 0.04 x 109/L margination or migration to inflammatory site

CAUSES acute stress and acute inflammatory

state epinephrine and adrenal corticoticoid

secretion Cushing’s syndrome

caused by excessive production of ACTH by the pituitary gland

BASOPHILIA count in above 0.2 x 109/L hypersensitivity, leukemia

CAUSES allergic reactions; hypothyroidism chronic myeloid leukemia, myeloid

metaplasia polycythemia vera, chronic hemolytic

anemia following splenectomy

BASOPENIA decrease count below 0.01 x 109/L diurnal [lowest in AM; highest in PM]

CAUSES sustained Tx w/ adrenal corticosteroid acute infection acute stress hyperthyroidism

MONOCYTOSIS increase count above 1.0 x 109/L indicates recovery from marrow hypoplasia,

dse, & acute infection if (+) in tuberculosis [poor prognosis]

CAUSES: subacute bacterial endocarditis fungi, ricketsia, protozoan, virus

infections

MONOCYTOPENIA decrease below 0.2 x 109/L follows administration of glucocorticoids

CAUSES: administration of prednisone Hairy cell Leukemia

LYMPHOCYTOSIS above normal count for age

ADULT: 1.5-4.0 x 109/L CHILD: 1.5-8.8 x 109/L

viral infections, antigen stimulation T – cells (highest @ birth) B – cells (remain stable for all stages of life)

LYMPHOCYTOSIS

CAUSES Human T Lymphotropic Virus Type I

asst’d w/ T-cell leukemia fever, lymphadenopathy, skin rash

Infectious Lymphocytosis contagious disease among children asst’d w/ coxsackie virus A, echovirus, adenovirus type 12 vomiting, fever, cutaneous rash, CNS involvement

Chronic Lymphocytosis common among adults w/c waxes and wanes for mons - yrs

Infectious Mononucleosis self-limited infectious dse w/c involves the RES 2O to EBV infection; (+) heterophil antibody fever, sore throat, lymphadenopathy (w/ ampicillin = rashes) associated w/ hemolytic anemia due anti–i antibody

production

LYMPHOCYTOSIS

Cytomegalovirus Virus infection fever, chills, profound malaise, myalgia, splenomegaly increased titer of Cold Aagglutinins, Rheumatoid

Factor, and Anti-Nuclear Antibody

Pertussis [Whooping cough] Bordetella pertussis inflammatory rxn of the entire RT

Toxoplasmosis

LYMPHOCYTOPENIA below normal count for age early stages of infection CAUSES

impaired lymphopoiesis or drainage of GIT lymphatics

increased adenocorticortical hormones administration of chemotherapeutic drugs irradiation Hodgkin’s and Non-Hodgkin’s lymphoma terminal cases of carcinoma, AIDS

PLASMACYTOSIS plasma cells are seen in circulating blood

CAUSES chronic infections, allergic states, neoplasms rubella, measles, chicken pox, mumps cutaneous exanthemas, mono, syphilis, SBE,

sarcoidosis, collagen diseases

LEUKEMOID REACTION excessive WBC response with out-pouring of

immature forms 50-100 x 109/mL leukocytosis w/ a shift-to-the-left

neutrophilic eosinophilic leukoerythroblastotic lymphocytic

Qualitative alteration

Morphologic alterations

Polymorphonuclear cells

Toxic granules primary or azurophil granules have retained their basophilic staining reaction lack of maturation

dark-blue to purple granules are PEROXIDASE (+)

Signs of toxicity: presence of basophilic azure granules presence of cytoplasmic vacuoles presence of sharp or blunt spicules from nucleus is transient

found in severe infections, cancer, hematoma, tissue undergoing necrosis

Döhle Inclusion Bodies small oval inclusion in the peripheral cytoplasm stain pale blue w/ Wright stain remnants of free ribosomes/RER arranged in parallel

rows accompany toxic granules

scarlet fever, other infectious diseases, burns, aplastic anemia, administration of toxic agents

May-Hegglin Anomaly rare autosomal dominant condition Involving the nonmuscle myosin heavy chain 9

linked to chromosome 22q12-13 (+) pale blue inclusions like Döhle Bodies

(randomly placed rods) PMNs, Eosinophils, Basophils Monocytes Giant platelets

Alder-Reilly Anomaly With large, darkly staining metachromatic granules

composed of mucopolysaccharides like toxic granulation but unrelated to infection found in ALL WBC Incomplete degradation of MPS There may be a structural abnormality in the

myeloperoxidase gene

Pelger-Huët Anomaly hereditary, autosomal dominant condition HYPOLOBULATION

failure of segmentation of granulocytic nuclei

cells are functionally normal Mutation of the lamin B receptor (integral protein in

the inner nuclear membrane) Chromosome band 1q41-43

Pseudo-Pelger-Huët Anomaly Acquired form of nuclear hyposegmentation Seen in myeloproliferative neoplasms

Fewer PMNs are affected (50%) Usually accompanied by other morphologic

indications of malignancy (e.g. blast forms)

bilobed neutrophils with more condensed chromatin.

Hereditary Neutrophil Hypersegmentation Benign Autosomal Dominant condition

Hypersegmented PMN w/o clinical S/S There is no macrocytic anemia

Myelokathexis Neutropenia with hypersegmented PMN Bone marrow hyperplasia of myeloid cells Pyknotic Increased apoptosis

Chédiak – Higashi Syndrome rare autosomal recessive disorder With enlarged lysosomal vesicles All cells are affected including the melanosomes of

melanocytes in the skin, dense granules of platelets, and leukocyte granules

Associated with a mutation in the LYST gene that encodes for a type of vesicle trafficking regulatory protein

frequent pyogenic infections, lymphoma-like phase, death ensues at early age

Functional abnormality

Lazy Leukocyte the actin filaments in the neutrophil is defective

chemotaxic response defective defective mobility

Chediak-Higashi PMNs are sluggish

Chronic granulomatous disease: Inability of phagocytes to produce superoxide and

reactive oxygen species Mutations in any of 4 genes for NADPH oxidase

Nitroblue tetrazolium reduction test Normal PMN – reduce the yellow water-soluble

nitroblue tetrazolium to a dark blue insoluble formazan

Job’s syndrome a familial disorder clinical laboratory observations are limited to the

monocytes & lymphocytes both cells may contain fine vacuolation

observed in 2 primary diseases: muscular dystrophy [directional motility impairment] xeroderma (ichthyosis) [patient has boils and

abscesses]

also found in Infections, toxic effect of ethanol, Jordan's anomaly

Monocytes and Macrophages

Lipid Storage Disorders

Gaucher’s Disease: deficiency of ß-glucocerebrosidase leading to an accumulation of its substrate, the fatty

substance glucocerebroside

Gaucher cell

Niemann – Pick Disease: is an autosomal recessive disorder affecting lipid

metabolism (the breakdown and use of fats and cholesterol in the body), in a way which causes harmful amounts of lipids to accumulate in the spleen, liver, lungs, bone marrow, and brain

deficiency of the enzyme sphingomyelinase Defective NPC1 and NPC2 genes that regulate

intracellular processing and transport of LDL- derived cholesterol

large cells filled with lipid droplets

Foamy Histiocyte in Nieman-Pick Disease

Tay-Sachs disease: deficiency of the enzyme hexosaminidase A occurs when harmful quantities of a fatty acid derivative

called a ganglioside accumulate in the nerve cells of the brain

Sea-blue histiocytosis: accumulation of phosphosphingolipids in cytoplasm

Neimann Pick vacuolization due to infection

Lymphocytes

Nuclear Clefting

Cytoplasmic Increased cytoplasm Vacuolization Azurophilic granulation

Atypical Lymphocyte/Reactive lymphocyte

Larger than normal size

Türk's cell or irritation leukocyte : a nongranular, mononuclear cell displays morphologic cxs of both an atypical lymphocyte

and a plasma cell

observed during severe anemia, chronic infections, and leukemoid reactions

Leukemoid Reaction An excessive leukocytic response in the peripheral

blood Due to elevation of cytokines or granulocyte colony-

stimulating factor by tumor

Neutrophilic Eosinophilic Eryhthroblastosis Leukoerythroblastosis Lymphocytic leukemoid reactions