1. Minimal Requirement for hematology
血液腫瘤科
廖浚凱 Aug 15, 2012

2. Outline
Anemia
Blood smear

3. Erythrocyte Development
EPO: 90% from kidney
10% from liver
The hemoglobin concentration in adults has a Gaussian distribution. The mean hematocrit value for adult males is 47% (± SD 7) and that for adult females is 42% (± 5). Any individual hematocrit or hemoglobin value carries with it a likelihood of associated anemia. Thus, a hematocrit of 39% in an adult male or <35% in an adult female has only about a 25% chance of being normal.

4. Hemoglobin
Fe + protoporphyrin α2β2
↓ ↓
heme globin ↓ Hb

5. Two main approaches for anemia that are not mutually exclusive:
1. Kinetic approach
2. Morphological approach

6. Kinetic approach of Anemia
Production?
Survival/ Destruction?
The key test is the …..

7. Reticulocyte Production Index— an estimate of marrow production relative to normal
Hct
Corrected Ret= Ret(%) * 45
Corrected Ret
RPI=
Maturation index

8. RPI (kinetic approach)
RPI are the most helpful:
extremely low (<0.1%)
AA/ PRCA are the first considerations
extremely high (>3%)
Blood loss/ hemorrhage
Hemolytic anemia (although 25% AIHA have normal RPI)

10. Morphological Approach-1
MCV>115
Vit B12, Folate
Drugs that impair DNA synthesis (AZT, chemotherapy, azathioprine)
MDS
MCV
Ditto
Reticulocytosis
Hypothyroidism
Alcoholism/ liver dz

11. Morphological Approach-2
Normocytic (MCV )
Anemia of chronic disease (ACD)
Mixed deficiencies
Renal failure
BM dz (ex AA, MDS, MM…)
Microcytic (MCV<80)
Iron deficiency anemia
Thalassemia
Anemia of chronic disease (ACD, 30-40%)
Sideroblastic anemia
Pb intoxification

12. Iron and IDA

13. Distribution of Iron in Adults
In the balanced state, 1 to 2 mg of iron enters and leaves the body each day. Dietary iron is absorbed by duodenal enterocytes. It circulates in plasma bound to transferrin. Most of the iron in the body is incorporated into hemoglobin in erythroid precursors and mature red cells. Approximately 10 to 15 percent is present in muscle fibers (in myoglobin) and other tissues (in enzymes and cytochromes). Iron is stored in parenchymal cells of the liver and reticuloendothelial macrophages. These macrophages provide most of the usable iron by degrading hemoglobin in senescent erythrocytes and reloading ferric iron onto transferrin for delivery to cells.

14. Storage iron Circulating iron  RBC iron  Tissue iron
Figure 105-2: Laboratory studies in the evolution of iron deficiency. Measurements of marrow iron stores, serum ferritin, and total iron-binding capacity (TIBC) are sensitive to early iron-store depletion. Iron-deficient erythropoiesis is recognized from additional abnormalities in the serum iron (SI), percent transferrin saturation, the pattern of marrow sideroblasts, and the red cell protoporphyrin level. Patients with iron deficiency anemia demonstrate all the same abnormalities plus hypochromic microcytic anemia.

15. IDA Presentation Presentation Diagnosis Progressive MCV ↘
Progressive RBC ↘
Typically high RDW
Typically high MCV/RBC
Typically mild PLT ↑
Ferritin: low (N=20-300)
Iron/TIBC <16% (N=~33%)
BM iron stain

16. Causes of IDA Increased iron requirement Inadequate iron supply
Hypermenorrhea
GI blood loss– hemorrhoid, PUD, GI cancer, angiodysplasia
Factitious removal
Hemolysis
Hemodialysis
Hookworm infestation
Rapid growth of teenage
Pregnancy and lactation
Poor nutritional intake
Malabsorption
Gastrectomy (may also has Vit B12 deficiency)

17. Iron Supply Oral: usually 3 months to restore iron storage IV
Ferrum chewable (Fe 3+) 100mg/tab
Hematonic (Fe 2+) 50mg/tab IV
Atofen (!! Risk of allergy and anaphylaxis—0.6%)

18. Thalassemia

20. Hb Gene Harrison’s Principles of Internal Medicine 15th Ed. 2001
Figure 106-1: The globin genes. The -like genes ( , ) are encoded on chromosome 16; the -like genes ( , , , ) are encoded on chromosome 11. The and genes encode embryonic globins.

21. Thalassemia Presentation
Diagnosis
Exclude IDA
Hb electrophoreis:
Hb A2>3.5% or HbF>2%  β-thalassemia
HbH(+)  α-thalassemia with ¾ defect (HbH dz)
HbA2 and HbF: N  α-thalassemia with ¼ or 2/4 defect
Gene diagnosis
Constant low MCV
Constant high RBC
Typically low RDW
Typically low MCV/RBC
Typically iron storage ↗

22. Gene Level of Thalassemia in Taiwan
α-thalassemia: Prevalence 4%
--SEAα0 deletion
-α3.7 deletion
-α4.2 deletion
HbQS or HbCS
β-thalassemia: Prevalence 2%
Codon 41/42 TCTT deletion β0
IVS II 654 C-> T point-mutation β0
Codon 17 A-> T β0
Promoter 28 A-> G β+
HbE (Codon 26 G-> A) β+
??% α + β-thalassemia (Severity?)

23. 優生學的理由
β –Major (終身輸血)
Hb H disease (黃疸)
Hydrops fetalis (死胎)

24. Thalassemia Treatment
Mild: None
Severe:
Folic acid
RBC transfusions + iron chelators
Allo-SCT

25. Megaloblastic Anemia

26. Figure 107-2: The assimilation of cobalamin
Figure 107-2: The assimilation of cobalamin. On entering the stomach, dietary cobalamin (Cbl) forms a complex with R binding protein. As this protein is digested in the small intestine, cobalamin is transferred to intrinsic factor (IF). This complex passes through the intestine until it reaches specific receptors on the mucosa of the distal ileum. The internalized Cbl is then transferred to transcobalamin II (TC II), which circulates in the plasma until it binds to receptors on cells throughout the body and is internalized.

27. Megaloblastic Anemia Presentation
Diagnosis
High high MCV
Pancytopenia
Hypersegmented PMN
Typically high RPI, hemolysis (LDH ↗), indirect hyperbilirubinemia
Tinnitus or other neurological presentation
Vegetarism (奶, 蛋, 維他命)
Gastrectomy or Pernicious anemia
??Schilling test
Low Vit B12 or folic acid
Vit B12: 270~400: empirical try
Vit B12< 270: definite deficiency

28. Remember Pancytopenia
P: PNH
A: Asplatic anemia
N: Neoplasm/ Near neoplasm (including MDS)
C: Cirrhosis/ Connective tissue disease
Y: Vit B12/ Folic acid
T: Toxin/ Drug
O: Overwhelming sepsis (Hemophagocytic syndrome)/ Others

29. Vit B12/Folate Deficiency Anemia Treatment
Vit B12 deficiency:
Vit B12 1 mg im qd *5 q1wk *4  q1m*3  q6m
R/I pernicious anemia (Anti-parietal Ab, anti-IF Ab and PES)
Thyroid dz
Gastric cancer
Folate deficiency: Improved diet, folic acid

30. Usually rapid response Most important F/U Reticulocyte, LDH
Harrison’s Principles of Internal Medicine 15th Ed. 2001
Figure 107-3: Hematologic response of a patient with pernicious anemia to an intramuscular injection of 100 g cobalamin on day 0.

31. Hemolytic Anemia

32. Is there hemolysis? Damaged RBCs on smear Marrow response to hemolysis
spherocytes (immune hemolysis, HS)
RBCs fragments (microangiopathic anemias)
Marrow response to hemolysis
polychromasia on smear
reticulocytosis
erythroid hyperplasia in marrow
Biochemical evidence of RBCs destruction
Indirect hyperbilirubinemia
increased LDH
decreased/absent haptoglobin

33. Extravascular vs Intravascular hemolysis
Extravascular Intravascular
Test Hemolysis Hemolysis
LD á áá
bilirubin á á
haptoglobin N to absent absent
hemoglobinuria absent present
free Hb in plasma absent present
urine hemosiderin absent present

34. An approach to hemolytic anemia
Immune
Non-immune
Congenital
Acquired
Autoimmune
Alloimmune
Drug-induced
Defects of:
Membrane/ skeleton
(eg. Hereditary spherocytosis)
Enzymes
(eg. G6PD deficiency)
Hemoglobinopathy
PNH
Infections
sepsis
malaria
Mechanical
Prosthetic heart valve
Microangiopathic HA (TTP, HUS, DIC)
Hypersplenism

35. D/D of AIHA Warm AIHA Cold AIHA
RBC’s coated with IgG, Fix complement poorly (usually C3 only)
RBC’s coated with IgM which fixes complement
Younger age
Older age
extravascular hemolysis
(Spleen is primary site of destruction)
Intravascular hemolysis
(Liver is primary site of destruction)
Spherocytes on PB smear
Agglutination on PB smear
70% associated with other illnesses
90% associated with other illnesses
Treatment: steroids, Splenectomy
Rituximab
Immunosuppressants
Treatment: avoidance of cold
Poor response to steroids, splenectomy
Plasmapheresis in refractory cases

36. D/D of ACD and IDA
ACD may concurrently coexist with true iron deficiency
(In this situation, iron/TIBC is more reliable than ferritin)

37. 貧血 分類： 重要指標： 依血球大小及形態： 依製造功能 網狀性紅血球值〈Reticulocyte count〉 乳酸脫氫脢〈LDH〉
紅血球偏小性貧血：海洋性貧血、缺鐵性貧血、慢性疾病相關之貧血
正常紅血球大小之貧血
紅血球偏大性貧血：維他命B12缺乏或葉酸缺乏性貧血、網狀紅血球增加之貧血〈溶血急性出血〉
依製造功能
製造不足：
骨髓造血功能不足、再生不良性貧血、造血元素缺乏性貧血、缺鐵性貧血、純紅血球製造不良、其他疾病合併骨髓侵犯
紅血球生成素〈Erythropoietin〉不足：腎衰竭、內分泌失調、營養 不良、 蛋白質不足
破壞或流失增加：溶血性貧血、出血、脾臟腫大性貧血
重要指標：
網狀性紅血球值〈Reticulocyte count〉
乳酸脫氫脢〈LDH〉
膽紅素〈Bilirubin〉
血紅素結合素〈Heptoglobin〉

38. Blood smear teaching

39. Burr cells Altered lipid in cell membrane artifact Uremia gastric CA
transfused old blood

40. Elliptocytes/ovalocytes
Abnormal cytoskeletal proteins
Hereditary elliptocytosis

41. Howell Jolly body Nuclear remnant - DNA hemolytic anemia
Absent or hypofunction spleen

42. Schistocyte/helmet cells
Fragmented (mechanical or phagocytosis)
DIC
TTP
HUS
Vasculitis
prosthetic heart valve
severe burns

43. Sickle cells Molecular aggregation of Hgb-S SS, SC, S-thal
rarely S-trait

44. NRBC
Common in newborn
severe degree of hemolysis

45. Spherocyte Absent central pallor look smaller Hereditary spherocytosis
immune hemolytic anemia

46. Target cells Increased redundancy of membrane hemoglobinopathies
thalassemia
liver disease

47. Tear drop cells Distorted drop shaped Smear artifact myelofibrosis
promyeloblastic leukemia
space occupying lesions of marrow

48. Rouleaux formation
Increased serum protein levels
Multiple myeloma

49. Red cell Agglutination

50. 血球成熟之變化 性質 成熟之變化 細胞 大小 大－＞小(megakaryoblas除外) 細胞質 量 顏色 顆粒 少－＞多
細胞 大小
大－＞小(megakaryoblas除外)
細胞質 量 顏色 顆粒
少－＞多
深藍－＞淡藍－＞橘紅(如RBC)
多－＞少或消失
細胞核 染色質 顏色
圓，卵圓－＞內凹，變小－＞分葉－＞消失
細－＞粗
紅紫－＞藍紫
核/質比
比例減少

51. 血球染色特徵 細胞成分 顏色 核仁 染色質 紅血球 淡藍 紫色 粉紅色 網狀紅血球顆粒 芽球細胞質 血小板 灰藍色 深藍色 初級顆粒
嗜中性顆粒
嗜酸性顆粒
嗜鹼性顆粒
毒性顆粒
紅紫色
橘紅色
黑紫色
藍黑色
Auer 小體
Cabot氏環
Howell-Jolly小體
Dohl小體
鮮藍色

52. WBC series Granulocytes Monocyte Lymphocyte Neutrophil Neutrophil
Eosinophil
Basophil
Monocyte
Lymphocyte
T cell, B cell
Neutrophil
Blast
Promyelocyte
Myelocyte
Metamyelocyte
Band
Segment

53. Granulocyte
0-5%
50-65%

56. Faggot cell
Auer Rods
Faggot Cells

57. Pancytopenia with macrocytic anemia
Causes
megaloblastic anemia
aplastic anemia
acute leukemia
myelodysplastic syndrome
chronic liver disease (esp. liver cirrhosis)
Work-up
Serum VitB12 & folic acid
reticulocytes
bone marrow study

58. Macrocytic anemia with unmeasurable RBC
RBC & Hct : unmeasurable RBC agglutination
Causes : autoimmune hemolytic anemia, mixed type or cold type
Work-up
peripheral blood smear
serum bilirubin (T/D), AST, LDH, haptoglobin, urine analysis, reticulocytes
Coombs’ test (direct and indirect)
ANA, VDRL, cold hemagglutinin antibody

59. 有獎徵答

60. ------------------------------------------------------------------------------------------------
檢驗項目 檢驗值 單位 H/L 參考值
=======================================================
WBC /CMM L M F3.5-11
RBC MILON/CMM L M F
HGB g/dL L M F12-16
HCT % L M41-53 F36-46
MCV FL H
MCH pg/Cell H
MCHC g/dL
RDW-SD % H
PLATELET /CMM H
RDW-CV % H
SEGMENT % L
LYMPHOCYTE %
MONOCYTE %
EOSINOPHIL %
BASOPHIL %

61. IDA

66. Leukoerythroblastosis
Immature RBC (nucleated RBC) and myeloid cells in peripheral blood
Causes
Bone morrow disorders：
Infiltrative disorders or hematologic malignancy
Peripheral disorders：
Severe infection, major stress or operation, acute blood loss

67. Thrombocytosis Primary: Bone marrow disease Secondary (Reactive)
Myeloproliferative disease
Secondary (Reactive)
Malignancy
Inflammation or infection
Connective tissue disorder
Blood loss or anemia
Splenectomy

68. THANKS