1. Overview of Hematology
Dr. Gamal Badr
PhD in Immunology (Paris Sud University, France)
Associate Professor of Immunology
Assiut University, Egypt
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Websites: orcid.org/

2. Hematology
Hematology, also spelled haematology, is the branch of internal medicine, physiology, pathology, clinical laboratory work, and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, and prevention of blood diseases.

3. Topics Hematopoiesis Transfusion Complete blood count (CBC) Anemia
Polycythemia
Leukopenia
Leukemia and lymphoma
Myeloma
Coagulation

4. BLOOD IS A TYPE OF CONNECTIVE TISSUE WHAT DOES BLOOD DO?
Transportation
Oxygen
Nutrients
Hormones
Waste Products
Regulation
Fluid, electrolyte
Acid-Base balance
Body temperature
Protection
Coagulation
Fight Infections

5. Components of Blood Blood components are:
Suspension of cells in a solute of water, proteins, and electrolytes
Average volume is 5 liters
70mL per kg body weight
Blood components are:
A. Liquid component -Plasma (55%)
Plasma is a yellow colored solution containing a mixture of water, amino acids, proteins, clotting factors, carbohydrates, lipids, vitamins, hormones, electrolytes, and cellular wastes.

6. B. Cellular component (45%)
Thrombocytes/Platelets
Leukocytes/ white blood cells (WBCs)
Erythrocytes/ red blood cells (RBCs)

7. Complete Blood Count (CBC)
White blood cells (WBCs) Normal 4, ,000 /µℓ
Differential cells: Neutrophils, lymphocytes, monocytes, eosinophils, basophils, Dendritic cells.
Red blood cells (RBCs) ♂ 4.5 – 5.5 x 106/µℓ ♀ 4.0 – 5.0 x 106/µℓ
Hemoglobin (Hgb), Hematocrit (Hct)
The hematocrit is the percent of whole blood that is composed of red blood cells. The hematocrit is a measure of both the number of RBCs and the size of red blood cells.
Mean corpuscular volume (MCV)
is a measure of the average volume of a red blood corpuscle
Platelets (PLT) Normal 15, ,000 /µℓ

8. Hematopoiesis Development of all blood cells and other formed elements
Sites vary throughout development
Before birth: liver, spleen
Adult: bone marrow (BM) of axial skeleton.
Stem cells
Primitive; self-replicate and differentiate to become increasingly specialized progenitor cells which form mature cells
Process regulated by growth factors (interleukins, erythropoietin, thrombopoietin, G-CSF)
Early lineage division between progenitors for lymphoid and myeloid cells

9. Hematopoiesis

10. Thrombocytes/Platelets
Must be present for clotting to occur
Involved in hemostasis

11. Leukocytes/White Blood Cells (WBCs)
Granulocytes
Contain granules in their cytoplasm
Basophils
Eosinophils
Neutrophils
Agranulocytes
Contain no granules in their cytoplasm
Monocytes
Lymphocytes

12. Types and Functions of Leukocytes
CELL FUNCTION
Granulocytes
Neutrophil
Eosinophil
Basophil
Phagocytosis: early phase of inflammation
Phagocytosis: parasitic infections
Inflammatory response, allergic response
Agranulocytes
Lymphocyte
Monocyte
Cellular and humoral immune response
Phagocytosis: cellular immune response

13. Erythrocytes/Red Blood Cells (RBCs)
Immature RBC (circle and nucleated), while mature RBC is circle and non nucleated
Composed of hemoglobin (Hb or Hgb)
Erythropoiesis is the production of RBCs
Stimulated by hypoxia (decrease of O2 in the blood)
Controlled by erythropoietin (hormone synthesized in kidney)
Hemolysis is the destruction of RBCs
Releases bilirubin into blood stream
Normal lifespan of RBC = 120 days

14. Structures of the Hematologic System
Bone Marrow a primary lymphoid organ (Hematopoiesis)
Soft connective tissue in core of bones
The production of all types of blood cells (Hematopoiesis) generated by a remarkable self-regulated system that is responsive to the demands put upon it.
Liver
Receives 24% of the cardiac output (1500 ml of blood each minute)
Liver has many functions. The hematologic functions:
Liver synthesis plasma proteins including clotting factors and albumin
Liver clears damaged and non-functioning RBCs/erythrocytes from circulation
Spleen a secondary lymphoid organ exerts many functions:
Hematopoietic function: Produces fetal RBCs
Filter function: Filter and reuse certain cells
Immune function: Lymphocytes, monocytes
Storage function: 30% platelets stored in spleen

15. RBCs (erythrocytes)
Mature RBCs are biconcave disks that contain oxygen-carrying hemoglobin, discard their nuclei during development and so cannot reproduce or produce proteins.
In the embryo and fetus, RBCs production occurs in the liver and spleen; but after birth, it occurs in the bone marrow. Normal lifespan = 120 days
Reticulocytes (Immature red blood cells)
Calculating proportion within circulation assists
in determining cause of anemia
Normal % is 1-2%
Low % (< 0.4%) suggests decreased production (i.e. nutritional or marrow problem)
High % (< 3%) suggests bleeding or premature destruction of red blood cells (i.e. hemolysis)

16. Red Blood Cells
Blood
RBCs
Bone marrow
1 – 2%

17. RBC Production and Its Control
The total number of red blood cells remains relatively constant due to a negative feedback mechanism utilizing he hormone erythropoietin, which is released from the kidneys and liver in response to the detection of low oxygen levels.

18. Factors Affecting RBCs Production
Dietary Vitamins B12 and folic acid are needed for DNA synthesis, so they are necessary for the reproduction of all body cells, especially in hematopoietic tissue.
Dietary Iron is needed for hemoglobin synthesis.
Destruction of RBCs with age, RBCs become increasingly fragile and are damaged by passing through narrow capillaries.
Macrophages in the liver and spleen phagocytize damaged red blood cells.
Hemoglobin from the decomposed RBC is converted into heme and globin.
Heme is decomposed into iron which is stored or recycled and biliverdin and bilirubin which are excreted in bile.

19. Hematological Disorders
RBCs Disorders
&Others
Anemias
Benign & Malignant
WBCs Disorders
Hemostatic Disorders 1ry & 2ry
Transfusion Medicine

20. RBCS DISORDERS

21. RBCs Disorders Anemia Almost 1/3 of the world population is anemic!
Anemia is defined as a reduction in one or more of the major RBC measurements: Hgb, Hct, or RBC count
Normal Hgb concentration– 15 in males ; 14 in females
Patients are “anemic” when Hgb is < 12 g/dL
Determining reticulocyte count and MCV are first steps in determining etiology
MCV  = 10 x HCT(percent) ÷ RBC numbers (millions/µL)
Almost 1/3 of the world population is anemic!
Increase in hgb that occurs in men is mostly related to effect of androgens on release of erythropoietin ; gender disparity becomes less significant in advanced age

22. RBCs Disorders - Anemia
Manifestations related to duration and severity of anemia:
May provide important clues as to etiology
Body has physiologic responses to chronic anemia such that many patients are asymptomatic until Hgb < 8 g/dL
Fatigue, pallor, dyspnea, dizziness, ischemic pain, cognitive abnormalities
Two main approaches that are not mutually exclusive:
Morphological approach.
Biologic or kinetic approach.

23. Anemia - (Morphological approach)
By calculation from an independently-measured RBCs count and hematocrit:
MCV  (femtoliters) = 10 x HCT(percent) ÷ RBC (millions/µL)
The normal MCV ( fL)
Microcytosis – small cells (MCV <80) – microcytic anemia
Macrocytosis – large cells (MCV >100) – macrocytic anemia
Normocytic anemia
is defined as an anemia with a MCV of which is the normal range, but the HCT and Hbg is decreased

24. Microcytic Anemia (MCV <76 fL)
The normal MCV ( fL)
Microcytosis – small cells (MCV <80)
Most common type of anemia encountered in primary care
Differential diagnosis
Hemoglobinopathy (inherited)
Iron deficiency
Chronic disease (may also be normocytic)
Inflammation
Lead poisoning

25. Microcytic Anemia Peripheral blood smear
Microcytosis, Hypochromic (are paler than usual)

26. Macrocytic Anemia Macrocytosis – large cells (MCV >100)
Differential diagnosis
B12 deficiency
Pernicious anemia: (Biermer's anemia, Addison's anemia) is caused by loss of gastric parietal cells, which are responsible for the secretion of factors that are responsible for absorption of vitamin B12 in the ileum.
Folate deficiency
Check vitamin B12, RBC folate, fasting homocysteine (HC), and methylmalonic acid (MMA)
HC and MMA are elevated in subclinical B12 and folate deficiency
Medications associated with elevated MCV include…

27. Anemia - (kinetic approach)
Abnormality?
Production of RBCs
(hypoproliferation)
Survival/Destruction of RBCs
The key test is the reticulocyte count
Mechanisms of Anemia
Decreased erythrocyte production Erythrocyte loss
Decreased erythropoietin production Hemorrhage
Inadequate marrow response to erythropoietin Hemolysis

28. Anemia - (kinetic approach)
Mechanisms
Short survival/Destruction of RBCs/ loss of RBCs
Blood loss / hemorrhage
Accidents
Ulcer or surgery in Gastrointestinal tract (GI), menstruation
Hemolysis
Shortened RBC survival time.
Decreased production (hypoproliferative)
Nutritional deficiency (iron, B12, and folate)
Systemic illness (chronic kidney disease (CKD), cancer, rheumatologic disease, etc.)
Bone marrow disorders

29. RBCs Disorders - Anemia
Marrow production
Thalassemias
Myelodysplasia
Myelophthisic
Aplastic anemia
Nutritional deficiencies
Red cell destruction (hemolytic)
Hemoglobinopathies
Enzymopathies
Membrane disorders
Autoimmune

30. RBCs Disorders - Red cell destruction
Causes:
Elevated reticulocyte count
Mechanical
Autoimmune
Drug
Congenital

31. Red cell destruction -Hemolytic Anemia
History and physical findings
Hemolytic anemias are either acquired or congenital. The laboratory signs of hemolytic anemias include:
Increased LDH (Lactate dehydrogenase).
Increased bilirubin.
Increased reticulocyte count.
Decreased haptoglobin.
Urine hemosiderin
Jaundice is common
Occasional pain in the left upper abdominal region. (splenomegaly)

32. Red cell destruction -Hemolytic Anemia
Congenital
Membrane defects
Hereditary spherocytosis : auto-hemolytic anemia characterized by the production (RBCs) that are sphere-shaped, rather than bi-concave disk shaped
Hereditary elliptocytosis: also known as ovalocytosis, is an inherited blood disorder in which an abnormally large number of the patient's RBCs are elliptical rather than the typical biconcave disc shape.
Enzyme defects
Glucose-6-phosphate dehydrogenase (G6PD) deficiency: X-linked recessive hereditary disease.
Pyruvate kinase deficiency: is an inherited metabolic disorder of the enzyme Pyruvate kinase which affects the survival of RBCs and causes them to deform into echinocytes on peripheral blood smears.

33. Red cell destruction -Hemolytic Anemia
Congenital
Hemoglobin defects: diagnosed by hemoglobin electrophoresis.
Thalassemias: Genetic defect in hemoglobin synthesis
decreased synthesis of one of the 2 globin chains ( or )
Imbalance of globin chain synthesis leads to depression of hemoglobin production and precipitation of excess globin (toxic)
“Ineffective erythropoiesis”
Found in people of African, Asian, and Mediterranean heritage
Fe stores are usually elevated
The only treatments are stem cell transplant and simple transfusion.
Chelation therapy (administration of chelating agents to remove heavy metals from the body) to avoid iron overload has to be started early.

34. Red cell destruction -Hemolytic Anemia
Congenital
Hemoglobin defects:
Sickle cell disease
Single base pair mutation results in a single amino acid change.
Under low oxygen, Hgb becomes insoluble forming long polymers
This leads to membrane changes (“sickling”) and vasoocclusion
OXY-STATE
DEOXY-STATE

35. Red cell destruction -Hemolytic Anemia
Aquired
Classified according to site of RBC destruction and whether mediated by immune system
Intravascular
Extravascular
Autoimmune
Non-immune
Many causes… be aware of these –
Transfusion of incompatible blood
Prosthetic valves
Cancer
Drugs

36. RBCs Disorders - Anemia
Marrow production
Thalassemias
Myelodysplasia
Myelophthisic
Aplastic anemia
Nutritional deficiencies
Red cell destruction (hemolytic)
Hemoglobinopathies
Enzymopathies
Membrane disorders
Autoimmune

37. Marrow Production - Aplastic Anemia
Aplastic anemia is a disease in which the bone marrow, and the blood stem cells that reside there, are damaged. This causes a deficiency of all three blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia).
Acquired
Immunological
Toxins – Benzene
Drugs – methotrexate, chloramphenicol
Viruses – EBV, hepatitis
Hereditary
Fanconi anemia (FA) is the result of a genetic defect in a cluster of proteins responsible for DNA repair

38. Marrow Production - Aplastic Anemia
All lineages affected.
Most patients require red cell transfusions.
Transplant when possible.
Transfusions should be used selectively to avoid sensitization (no family donors!).

39. Polycythemia / Erythrocytosis
Polycythemia is increased total RBC mass - Hct > 65%
Above 65% blood viscosity rises exponentially
Complications: Polycythemic hyperviscosity is increased viscosity of the blood resulting from increased numbers of RBCs
Polycythemia occurs in 2-4% of newborns, half of them are symptomatic
Clinical signs result from regional effects of hyperviscosity and from the formation of microthrombi
Tissue hypoxia, Acidosis, Hypoglycemia
Organs affected: CNS, kidneys, adrenals, cardiopulmonary system, GI tract
Treatment
Phlebotomy (to cut a vein) is the process of making an incision in a vein .
Myelosupressive agents: new therapeutic agents such as: interferon alfa-2b (Intron A) therapy, agents that target platelet number (e.g., anagrelide [Agrylin]), and platelet function (e.g., aspirin).

40. Benign WBCs Disorders

41. Leukopenia (Leukocytopenia) -
Leukopenia: is a decrease in the number of WBCs
Neutropenia is most common cause
Absolute neutrophil count (ANC) < 1.5 x 109 cells/L
Many causes
Benign racial neutropenia common
African Americans and Yemenite Jews may have ANC as low as 1.0
Viral infections
Epstein-Barr, Hepatitis B, HIV
Drugs
Careful review of medications ; be suspicious of any medication recently started in patient with acute onset neutropenia
Splenomegaly
Autoimmune disorders
SLE (lupus), Rheumatoid Arthritis, etc.
Bone marrow disorders

42. Leukocytosis Leukocytosis: is an increase in the number of WBCs
WBC count > 11,000
Determine which type of WBC is leading to the leukocytosis
Neutrophilia = most common
Causes:
Infection
Connective tissue disorders
Medications (especially steroids, growth factors)
Cancer Myeloproliferative disorders
Cigarette smoking
Stress (physiologic)
Pain, trauma
Idiopathic (unknown cause)

43. Leukocytosis
Patients with acute bacterial infection often present with neutrophilia and band formation
Bands = young neutrophils
Viral infections are usually associated with low WBCs ; leukocytosis may suggest complications
Ex: bacterial pneumonia with underlying influenza infection

44. Leukocytosis
Lymphocytosis: is an increase in the number or proportion of lymphocytes in the blood
Causes:
Viral infections: HBV, HCV, EBV, CMV
Tuberculosis
Pertussis
Drug Reaction
Stress (physiologic): Trauma, cardiac arrest, etc
Malignancy: ALL, CLL, lymphoma

45. Malignant WBCs Disorders

46. Myeloid vs. Lymphoid Myeloid malignancies • Acute myeloid leukemia
• Chronic myeloproliferative disorders
Lymphoid malignancies
• B-cell malignancies
• Acute lymphoblastic leukemia, B-cell type
• Non-Hodgkin’s lymphoma, B-cell types
• Myeloma
• T-cell malignancies
• Acute lymphoblastic leukemia, T-cell type
• Non-Hodgkin’s lymphoma, T-cell types
• Hodgkin’s disease

47. Leukemia
Leukemia is a type of cancer of the blood or bone marrow characterized by an abnormal increase of immature WBCs called “blasts".
Leukemia is a broad term covering a spectrum of diseases. In turn, it is part of the even broader group of diseases affecting the blood, bone marrow, and lymphoid system.

48. Chronic Leukemia Chronic myelogenous leukemia (CML)
Translocation between long arms of chromosomes 9 and 22 ; “Philadelphia Chromosome” ; bcr/abl protein

49. Chronic Leukemia Chronic lymphocytic leukemia (CLL)
Clonal malignancy of B-lymphocytes
Course is usually indolent ; affects older patients, average age at diagnosis is 70 years
Often found incidentally
Fatigue, lymphadenopathy common
Hepatosplenomegaly
Immunodeficiency is major clinical concern
Lymphocytes are defective ; do not make antibodies in response to antigens
Treatment
Observation
Indications for therapy include progressive fatigue, symptomatic lymphadenopathy, anemia, or thrombocytopenia
Gamma globulin (IVIG) used in patients with recurrent or severe bacterial infections
Allogeneic BMT is potentially curative but reserved for select patients
Prognosis improving ; survival is years with early disease

50. Acute Leukemia Acute Myelogenous Leukemia (AML) Most common in adults
Usually no apparent cause
Exposure to radiation, benzene, and certain chemotherapy drugs (alkylators) associated with leukemia
Underlying myelodysplastic syndrome (MDS) is risk factor
Symptoms and signs
Related to replacement of marrow space by malignant WBCs
Patients often very ill for period of just days or weeks
Skeletal pain
Bleeding
Gingival hyperplasia
Infection
Pancytopenia with circulating blasts is hallmark ; bone marrow biopsy required
Auer rods on peripheral smear are pathognomonic

51. Acute Leukemia AML Acute Lymphocytic Leukemia (ALL) Management
Immediate referral to hematologist
Patients often hospitalized for therapy
Anthracycline (daunorubicin or idarubicin) plus cytarabine results in CR in 80% of patients < 60 years
Additional high dose chemotherapy following CR leads to cure rate of 35-40%
Acute Lymphocytic Leukemia (ALL)
More often seen in children

52. Lymphoma Hodgkin’s disease Malignancy of B-lymphocytes
Reed-Sternberg cells
Various subtypes ; “nodular sclerosing” is most common
Non-Hodgkin’s Lymphoma (NHL)
Heterogeneous group of cancers affecting lymphocytes
Usually classified by histologic grade (low to high)
Follicular lymphoma
Small lymphocytic lymphoma
Diffuse large B-cell lymphoma
Burkitt’s lymphoma
Many others

53. Myeloma Malignancy of plasma cells
Abnormal paraproteins are created leading to systemic problems
IgG – 60%
IgM – 20%
Primarily disease of elderly (median age 65 years)
Most common hematologic malignancy among African Americans ; #2 among Caucasians