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CLINICAL HEMATOLOGY 1 CLINICAL HEMATOLOGY Editor Gamal Abdul Hamid, MD,PhD Associate Professor Faculty of Medicine and Health Sciences University of Aden CLINICAL HEMATOLOGY 2 PREFACE Clinical Hematology, first edition is written specifically for medical students, the clinician and resident doctors in training and general practioner. It is a practical guide to the diagnosis and treatment of the most common disorders of red blood cells, white blood cells, hemostasis and blood transfusion medicine. Each disease state is discussed in terms of the pathophysiology, clinical and paraclinical features which support the diagnosis and differential diagnosis. We bring together facts, concepts, and protocols important for the practice of hematology. In addition this book is also supported with review questions and quizzes. G.A-H 2012 CLINICAL HEMATOLOGY 3 CONTENTS Preface 1. Hematopoiesis 7 2. Anemia 26 3. Iron Deficiency Anemia 32 4. Hemolytic Anemia 41 5. Sickle Cell Hemoglobinopathies 49 6. Thalassemia 57 7. Hereditary Hemolytic Anemia 63 8. Acquired Hemolytic Anemia 68 9. Macrocytic Anemia 75 10. Bone Marrow Failure, Panctopenia 87 11. Spleen 95 12. Acute Leukemia 99 13. Chronic Myeloproliferative Disorders 125 14. Chronic Lymphoproliferative Disorders 137 15. Malignant Lymphoma 147 16. Multiple Myeloma and Related Paraproteinemia 171 17. Hemorrhagic Diseases 179 18. Transfusion Medicine 201 19. Bone Marrow Transplantations 214 CLINICAL HEMATOLOGY 4 Appendices: I. Hematological Tests and Normal Values 221 II. CD Nomenclature for Leukocytes Antigen 226 III. Cytotoxic Drugs 228 IV. Drugs Used in Hematology 230 Glossary 232 Answers 246 Bibliography 247 CLINICAL HEMATOLOGY 5 CLINICAL HEMATOLOGY 6 HEMATOPOIESIS 1 All of the cells in the peripheral blood have finite life spans and thus must be renewed continuously. The mechanisms responsible for regulating steady-state hematopoiesis and the capacity to modulate blood cell production in response to stresses such as anemia or infection consist of a series of progenitor cells in the bone marrow and a complex array of regulatory factors. It is the process of blood cell production, differentiation, and development. The hematopoietic system consists of the bone marrow, liver, spleen, lymphnodes, and thymus. It starts as early as the 3rd week of gestation in the yolk sac. By the 2nd month, hematopoiesis is established in the liver and continuous through the 2nd trimester. During the 3rd trimester it shifts gradually to bone marrow cavities. During infancy: all marrow cavities are active in erythropoiesis "Red Marrow". During childhood: erythropoiesis becomes gradually restricted to flat bones as; skull, vertebrae, sternum, Ribs and pelvic bones, in addition to ends of long bones. The shafts of long bones become populated by fat "yellow marrow". Blood Cell Development The pluripotent stem cell is the first in a sequence of steps of hematopoietic cell generation and maturation. The progenitor of all blood cells is called the multipotential hematopoietic stem cell. These cells have the capacity for self-renewal as well as proliferation and differentiation into progenitor cells committed to one specific cell line. The multipotential stem cell is the progenitor for two major ancestral cell lines: Lymphocytic and non-lymphocytic cells. The lymphoid stem cell is the precursor of mature T cells or B cells/ plasma cells. The non-lymphocytic (myeloid) stem cell is progress to the progenitor CFU-GEMM (colony-forming unit granulocyte- erythrocyte-monocyte-megakaryocyte). The CFU-GEMM can lead to the formation of CFU-GM (CFU-granulocyte-macrophage / monocyte), CFU-Eo (CF-Eosinophil), CFU-Bs (CFU-basophil) And CFU-MEG (CFU-Megakaryocyte). In erythropoiesis, the CFU-GEMM differentiates, into the BFU-E (Burst-Forming unit Erythroid). Each of the CFUs in turn can produce a colony of one hematopoietic lineage under appropriate growth conditions. CFU-E is the target cells for erythropoietin. Hematopoietic Growth Factors The hematopoietic growth factors are glycoprotein hormones that regulate the proliferation and differentiation of hematopoietic progenitor cells and the function of mature blood cells. These growth factors were referred to as colony stimulating factors (CSFs) because they stimulated the formation of colonies of cells derived from individual bone marrow progenitors. Erythropoietin, granulocyte-macrophage colony stimulating factors (GM-CSF) granulocyte colony stimulating factor (G-CSF), macrophage colony stimulating factor (M-CSF) and interleukin-3 are representative factor that have been identified, cloned and produced through recombinant DNA technology. The hematopoietic growth factors interact with blood cells at different levels in the cascade of cell differentiation from the multipotential progenitor to the circulating mature cell. CLINICAL HEMATOLOGY 7 Table 1.1: Human hematopoietic growth factors Growth Factor Source Major Function GM-CSF T-Lymphocyte, endothelial Stimulates production of cells, Fibroblasts neutrophils, eosinophils, monocytes, red cells and platelets. G-CSF Monocytes, Fibroblasts Stimulates production of neutrophils. M-CSF Macrophages, endothelia Stimulates production of cells monocytes ERYTHROPOIE Peritubular cells, Liver, Stimulates production of red TIN Macrophages cells. IL-1 Macrophages, activated Cofactor for IL-3 and IL-6. lymphes, endothelial cells. Activated T cells IL-2 Activated T cells T cell growth factor. Stimulates IL-1 synthesis. Activated B cells and NK cells IL-3 T cells Stimulates production of all non-lymphoid cells. IL-4 Activated T cells Growth factor for activated B cells, resting T cells and mast cells. IL-5 T cells Induces differentiation of activated B cells and eosinophils. IL-6 T cells Stimulates CFU-GEMM Stimulates Ig synthesis IL-7 T cells, Fibroblasts, Growth factor for pre B cells Endothelial cells Development and Maturation Erythrocytes are rapidly maturing cells that undergo several mitotic divisions during the maturation process. The Pronormoblast" is the first identifiable cell of this line followed by the " Basophilic normoblast ", polychromatic normoblast ", orthochromatic normocyte " and reticulocyte stages in the bone marrow. Reticulocytes enter the circulating blood and fully mature into functioned erythrocytes. A defect in nuclear maturation can occur. This is referred to as megaloblastic maturation. In this condition, the nuclear maturation, which represents an impaired ability of the cell to synthesize DNA, lags behind the normally developing cytoplasm. Reticulocytes represent the first nonnucleated stage in erythrocytic development. Although the nucleus has been lost from the cell by this stage, as long as RNA is present, synthesis of both protein and heme continues. The ultimate catabolism of RNA, ribosome disintegration, and loss of mitochondria mark the transition from the reticulocyte stage to full maturation of the erythrocyte. If erythropoietin stimulation produces increased numbers of immature reticulocytes in the blood circulation, these Reticulocytes are referred to as stress or shift reticulocytes. Supravital stains such as new methylene blue are used to perform quantitative determination of blood reticulocytes. CLINICAL HEMATOLOGY 8 Figure 1.1: Developemntal characteristics of erythrocytes Pronormoblast Basophilic Normoblast Size 12- 19 m in Size 12- 17 m in diameter diameter N:C ratio 4: 1 N:C ratio 4:1 Nucleus: Nucleus Large, round Nuclear chromatin more clumped nucleus Nucleoli usually not apparent Chromatin has a fine Cytoplasm: Distinctive pattern 0-2 nucleoli’ basophilic colour Cytoplasm: distinctive basophilic colour without granules Polychromatic Normoblast Orthochromic Normoblast or Size 11-1 m in nucleated RBC diameterN:C ratio 1:1 Size: 85-12 m Nucleus: Nucleus: Increased clumping of Chromatin pattern is tightly the chromatin condensed. Cytoplasm: Colour: Cytoplasm: Variable, with Colour: reddish-pink pink staining (acidophilic) Mixed with Basophilia Erythrocyte Reticulocyte (Supravital Average diameter 6-8 m stain) Size 7-10 m Cell is anuclear Polychromatic Erythrocyte Diffuse reticulum (Wright stain) Cytoplasm: Overall blue appearance Pronormoblast (1) basophilic normoblast(2) polychromatic N (3- 4) Orthochromatic normoblast (5-6) (1. CLINICAL HEMATOLOGY 9 The myeloblast is the first identifiable cell in the granulocytic series. Myeloblast constitutes approximately 1% of the total nucleated bone marrow cells. This stage lasts about 15 hours. The next stage, the promyelocyte, constitutes approximately 3% of the nucleated bone marrow; this stage lasts about 24 hours. The myelocyte is the next maturational stage, with approximately 12% of the proliferative cells existing in this stage. The stage from myelocyte to metamyelocyte lasts an average 4.3 days.The time requerd for the division and maturation of a myeloblast to a mature granulocyte is 5-12 days. Two stages of granulocytes are observed in the circulating blood: the band form of neutrophils, eosinophils and basophils and in end stage of maturation. The normal number of neutrophilic granulocytes in the peripheral blood is about 2500-7500/l. Neutrophilic granulocytes have a dense nuleus split into two to five lobes and a pale cytoplasm. The cytoplasm contains numerous pink blue or gray blue granules. Two types of granules can be distinguished morphologically; primary or azurophilic granules which appear at the promyelocyte stage and secondary granules, which appear later. The primary granules contain myeloperoxidase, and acid hydrolase, whereas lyszymes,
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