Predominance of Mononuclear Round to Oval Cells Table S
The cell counts per microliter show a wide range of values and depend on a variety of conditions even in normal blood. Any disease may therefore result in higher leukocytosis or lower cell counts leukopenia . The assessment of cell counts requires the knowledge of normal values and their ranges spreads Table 2, p. 12 . The most important diagnostic indicator therefore is not the cell count but the cell type. In a first assessment, mononuclear round to oval and polynuclear segmented cells are...
Cytomorphological Anemias with Erythrocyte Anomalies
Microspherocytosis This corpuscular form of hemolysis is characterized by dominant genetic transmission, splenomegaly, and a long uneventful course with occasional hemolytic crises. Blood analysis shows erythrocytes which appear strikingly small in comparison with leukocytes. The central light area is absent or only faintly visible, since they are spherical in cross-section rather than barbell-shaped. The abnormal size distribution can be measured in two dimensions and plotted using Price-Jones...
Clinically Relevant Classification Principle for Anemias Mean Erythrocyte
In current diagnostic practice, erythrocyte count and hemoglobin content grams per 100 ml in whole blood are determined synchronously. This allows calculation of the hemoglobin content per individual erythrocyte mean corpuscular hemoglobin, MCH using the following simple formula p. 10 The mean cell volume, hematocrit, MCH, and erythrocyte size can be used for various calculations Table 22 methods p. 10, normal values Table 2, p. 12 . Despite this multiplicity of possible measures, however, in...
Bone Marrow Carcinosis and Other SpaceOccupying Processes
Anemia resulting from bone marrow infiltration by growing, space-occupying tumor metastases can in principle be normochromic. However, under the indirect influence of the underlying disease, it tends more often to be hypochromic secondary anemia . Normoblasts in the differential blood analysis Fig. 9a, p. 33 particularly suggest the possibility of bone marrow carcinosis, because their presence implies destruction of the bone marrow-blood barrier. Usually, bone marrow carcinosis leads eventually...
Erythrocyte Inclusions
Erythrocytes normally show fairly homogeneous hemoglobinization after panoptic staining only after supravital staining p. 155 will the remains of their ribosomes show as substantia granulofilamentosa in the reticulocytes. Under certain conditions during the preparation of erythrocytes, aggregates of ribosomal material may be seen as basophilic stippling, also visible after Giemsa staining Fig. 55a . This is normal in fetal and infant blood in adults a small degree of basophilic stippling has...
Hyperchromic Anemias
In patients with clear signs of anemia, e.g., a sickly pallor, atrophic lingual mucosa, and sometimes also neurological signs of bathyanesthesia loss of deep sensibility , even just a cursory examination of the blood smear may indicate the diagnosis. Marked poikilocytosis and anisocytosis are seen, and the large size of the erythrocytes is particularly conspicuous in comparison with the lymphocytes, whose diameter they exceed mega-locytes . These are the hallmarks of macrocytic, and, with...
Normochromic Renal Anemia
Sometimes Hypochromic or Hyperchromic Normochromic anemia should also suggest the possibility of renal insufficiency, which will always lead to anemia within a few weeks. In cases of chronic renal insufficiency it is always present and may reach Hb values as low as 6 g dl. The anemia is caused by changes in the synthesis of erythropoietin, the hormone regulating erythropoiesis measurement of serum erythropoietin is an important diagnostic tool. Erythrocyte life span is also slightly reduced....
Bone Marrow Cytology in the Diagnosis of Hypochromic Anemias
So long as all other laboratory methods are employed, bone marrow cytology is very rarely needed in cases of hypochromic anemia. Bone marrow cytology is rarely strictly indicated after all other available diagnostic methods have been exhausted Table 22, p. 130 . However, in doubtful cases it can usually at least help to rule out malignant disease. In iron deficiency anemias of the most various etiologies, erythropoiesis is stimulated in a compensatory fashion, and the distribution of the...
Diseases of the Lymphatic System NonHodgkin Lymphomas
Malignant diseases of the lymphatic system are further classified as Hodg-kin and non-Hodgkin lymphomas NHL . NHL will be discussed here because most NHLs can be diagnosed on the blood analysis. gt Non-Hodgkin lymphomas arise mostly from small or blastic B-cells. gt Small-cell NHL cells are usually leukemic and relatively indolent, of the type of chronic lymphocytic leukemia and its variants. gt Blastic NHL precursor lymphoma is not usually leukemic. An exception is the lymphoblastic lymphoma,...
Elevated Eosinophil and Basophil Counts
In accordance with their physiological role, an increase in eosinophils gt 400 1, i.e. for a leukocyte count of 6000, more than 8 in the differential blood analysis is usually due to parasitic attack p. 5 . In the Western hemisphere, parasitic infestations are investigated on the basis of stool samples and serology. Strongyloides stercoralis in particular causes strong, sometimes extreme, elevation of eosinophils may be up to 50 . However, eosinophilia of variable degree is also seen in ameba...
Thalassemias
A special form of hypochromic anemia mostly affecting patients of Mediterranean descent presents with normal erythrocyte count, decreased MCH, and clinical splenomegaly. The smear displays erythrocytes with central hemoglobin islands target cells . These cells do not necessarily predominate in the CBC the most revealing field views show at most 50 target cells in addition to clear anisocytosis and frequent basophilic stippling. Occasional normoblasts give a general indication of increased...
Normochromic Hemolytic Anemias
Hemolytic anemias result from a shortened erythrocyte life span with insufficient compensation from increased erythrocyte production Table 24 . H Usually, hematopoiesis in the bone marrow is increased in compensation, and, depending on the course of the disease, may make up for the accelerated cell degradation for all or some of the time by recycling the iron as it becomes free. Accordingly, counts of the young, newly emerged erythrocytes reticulocytes are always raised, and usually sporadic...
Relative Lymphocytosis Associated with Granulocytopenia Neutropenia and
Neutropenia is defined by a decrease in the number of neutrophilic granulocytes with segmented nuclei to less than 1500 1 1.5 x 109 l . A neutrophil count of less than 500 l 0.5 x 109 l constitutes agranulocytosis. Absolute granulocytopenias with benign cause develop into relative lymphocytoses. In the most common clinical picture, drug-induced acute agranulocytosis, the bone marrow is either poor in cells or lacks granulopoietic precursor cells aplastic state , or shows a maturation block at...
Osteomyelosclerosis
When anemia accompanied by moderately elevated although sometimes reduced leukocyte counts, thrombocytopenia or thrombocytosis, clinically evident splenic tumor, left shift up to and including sporadic myeloblasts, and eosinophilia, the presence of a large proportion of red cellpre-cursors normoblasts in the differential blood analysis, osteomyelosclero-sis should be suspected. BCR-ABL gene analysis is negative. Pathologically, osteomyelosclerosis usually originates from megakaryocyte neoplasia...
Acute Leukemias
Acute leukemias are described in this place for morphological reasons, because they involve a predominance of mononuclear cells p. 63 . Although or perhaps because the term leukemia is relatively imprecise, an overview seems required Table 13 . The cellular phenomenon common to the different forms of leukemia is the rapidly progressive reduction in numbers of mature granulocytes, thrombocytes, and erythrocytes. Simultaneously, the leukocyte count usually increases due to the occurrence of...
Hypochromic Anemias Iron Deficiency Anemia
Most anemias are hypochromic. Their usual cause is iron deficiency from various causes Fig.44 . To distinguish quickly between real iron deficiency and an iron distribution disorder, iron and ferritin levels should be determined. Fig. 44 The most important reasons for iron deficiency according to Begemann Fig. 44 The most important reasons for iron deficiency according to Begemann Table 22 Diagnostic findings and work-up for the most important disorders of the red cell series Table 22...
Blast Crisis in Chronic Myeloid Leukemia
During the course of CML with or without therapy, regular monitoring of the differential smear is particularly important, since over periods of varying duration the relative proportions of blasts and promyelocytes increases noticeably. When the blast and promyelocyte fractions together make up 30 , and at the same time Hb has decreased to less than 10g dl and the thrombocyte count is less than 100 000 1, an incipient acute blast crisis must be assumed. this blast crisis is often accompanied or...
Reactive Left Shift
A relative left shift in the granulocyte series means less mature forms in excess of 5 band neutrophils the preceding, less differentiated cell forms are included and all transitional forms are taken into account. This left shift almost always indicates an increase in new cell production in this cell series. In most cases, it is associated with a raised total leukocyte count. However, since total leukocyte counts are subject to various interfering factors that can also alter the cell...
Steps in the Diagnosis of Chronic Myeloid Leukemia
Left-shift leukocytosis in conjunction with usually low-grade anemia, thrombocytopenia or thrombocytosis which often correlates with the migration of small megakaryocyte nuclei into the blood stream , and clinical splenomegaly is typical of CML. LDH and uric acid concentrations are elevated as a result of the increased cell turnover. The average typical cell composition is as follows in a series analyzed by Spiers about 2 myeloblasts, 3 promyelocytes, 24 myelocytes, 8 metamyelocytes, 57 band...
Bone Marrow Cell Composition and Principles of Analysis
As indicated above, and as will be shown below, almost all disorders of the hematopoietic system can be diagnosed using clinical findings, blood analysis, and humoral data. There is no mystery about bone marrow diagnostics. The basic categories are summarized here to give an understanding of how specific diagnostic information is achieved photomicrographs will show the appearance of specific diseases. Once the individual cell types, as given in the preceding pages, are recognized, it becomes...
Hypochromic Infectious or Toxic Anemia Secondary Anemia
Among the various causes of lack of iron for erythropoiesis see Fig.44, p. 129 , a special situation is represented by the internal iron shift caused by iron pull of the reticuloendothelial system RES during infections, toxic processes, autoimmune diseases, and tumors. Since this anemia results from another disorder, it is also called secondary anemia. The MCH is hypochromic, or in rare instances, normochromic, and therefore erythro-cyte morphology is particularly important to diagnosis. In...
Monocytosis
If mononuclear cells stand out in showing an unusually elaborate nuclear structure with ridges and lobes and a wider cytoplasmic layer with very delicate granules for characteristics see p. 46, for cell function, see p. 6 , and this is in the context of relative gt 10 or absolute monocytosis cell count gt 900 l , a series of possible triggers must be considered Table 12 . If the morphology does not clearly identify the cells as monocytes, then esterase assays should be done in a hematological...
Bone Marrow Medullary Stroma Cells
gt Fibroblastic reticular cells form a firm but elastic matrix in which the blood-forming cells reside, and are therefore rarely found in the bone marrow aspirate or cytological smear. When present, they are most likely to appear as dense cell groups with long fiber-forming cytoplasmic processes and small nuclei. Iron staining shows them up as a group of reticular cells which, like macrophages, have the potential to store iron. If they become the prominent cell population in the bone marrow,...
Reactive Lymphocytosis
Lymphatic cells show wide variability and transform easily. This is usually seen as enlarged nuclei, a moderately loose, coarse chromatin structure, and a marked widening of the basophilic cytoplasmic layer. Clinical findings, which include acute fever symptoms, enlarged lymph nodes, and sometimes exanthema, help to identify a lymphatic reactive state. Unlike the case in acute leukemias, erythrocyte and thrombocyte counts are not significantly reduced. Although the granulocyte count is...
Procedures Assays and Normal Values
I Since cell counts are affected by the state of the blood circulation, the conditions under which samples are taken should be the same so far as possible if comparable values are desired. This means that blood should always be drawn at about the same time of day and after at least eight hours of fasting, since both circadian rhythm and nutritional status can affect the findings. If strictly comparable values are required, there should also be half an hour of bed rest before the sample is...
The Individual Cells of Hematopoiesis
Immature Red Cell Precursors Proerythroblasts and Basophilic Erythroblasts Proerythroblasts are the earliest, least mature cells in the erythrocyte-forming series erythropoiesis . Proerythroblasts are characterized by their size about 20 m , and by having a very dense nuclear structure with a narrow layer of cytoplasm, homogeneous in appearance, with a lighter zone at the center they stain deep blue after Romanowsky staining. These attributes allow proerythroblasts to be distinguished from...
Introduction to the Physiology and Pathophysiology of the Hematopoietic System
The reason why quantitative and qualitative diagnosis based on the cellular components of the blood is so important is that blood cells are easily accessible indicators of disturbances in their organs of origin or degradation which are much less easily accessible. Thus, disturbances in the erythrocyte, granulocyte, and thrombocyte series allow important conclusions to be drawn about bone marrow function, just as disturbances of the lymphatic cells indicate reactions or disease states of the...
StepbyStep Diagnostic Sequence
On the basis of what has been said so far, the following guidelines for the diagnostic workup of hematological changes may be formulated 1. The first step is quantitative determination of leukocytes L , erythrocytes E and thrombocytes T . Because the normal range can vary so widely in individual cases Table 2 , the following rule of thumb should be observed A complete blood count CBC should be included in the baseline data, like blood pressure. 2. All quantitative changes in L E T call for a...