Normal Red Blood Cells - Peripheral Blood Smear

Peripheral Blood Cells A. Erythrocytes; B. Large Granular Lymphocyte; C. Neutrophil; D. Eosinophil; E. Neutrophil; F. Monocyte; G. Platelets; H. Lymphocyte; I. Band Neutrophil; J. Basophil

The red blood cells here are normal, happy RBC's The red blood cells here are normal, happy RBC's. They have a zone of central pallor about 1/3 the size of the RBC. The RBC's demonstrate minimal variation in size (anisocytosis) and shape (poikilocytosis).

Hypochromic Microcytic Anemia (iron deficiency)

The RBC's here are smaller than normal and have an increased zone of central pallor. This is indicative of a hypochromic (less hemoglobin in each RBC) microcytic (smaller size of each RBC) anemia. There is also increased anisocytosis (variation in size) and poikilocytosis (variation in shape).

Koilonychia - Iron Deficiency

Macroovalocytes and Hypersegmented Neutrophil

Here is a hypersegmented neutrophil that is present with megaloblastic anemias. There are 8 lobes instead of the usual 3 or 4. Such anemias can be due to folate or to B12 deficiency. The size of the RBC's is also increased

Bone marrow -- Megaloblastic anemia -- nuclear/cytoplasmic asynchrony,

Markedly hypocellular BM - Aplastic Anemia

Breast cancer replacing BM

Spherocytes Lab: moderate anemia, spherocytes, reticulocytes BM - erythroid hyperplasia Coomb’s test - negative

Hemoglobin Precipitates -- Heinz bodies G6PD Deficiency

Bite Cell -- G6PD Deficiency Clinical? X linked, African American Males, only symptomatic during oxidative stress (meds, fava beans)

Sickle Cells -- Clinical stuff: microvascular occulusions lead to tissue infarcts and pain, autosplenectomy (so no splenomegaly), increased Salmonella osteomyelitis, some aplastic crises (Parvovirus)

Sickle cell anemia in sickle cell crisis Sickle cell anemia in sickle cell crisis. The abnormal hemoglobin SS is crystalizes when oxygen tension is low, and the RBC's change shape to long, thin sickles that sludge in capillaries, further decreasing blood flow and oxygen tension. Persons with sickle cell trait (Hemoglobin AS) are much less likely to have this happen.

Mechanical trauma -- schistocytes

Malaria in RBCs -- most common hemolytic anemia Cyclical hemolysis produces fever and chills, splenomegaly

Activated neutrophil - Dohle body

Leukemoid reaction (toxic granulation)

Reactive Lymphocyte - Infectious Mononucleosis

Normal bone marrow. Note the presence of megakaryocytes, erythroid islands, and granulocytic precursors. This marrow is taken from the posterior iliac crest in a middle aged person, so it is about 50% cellular, with steatocytes mixed with the marrow elements.

Bone Marrow, Acute Leukemia Age distributions? ALL -- kids (4 yrs peak incidence) AML -- Adults

Bone marrow acute leukemia Symptoms? Fatigue (Anemia), Bleeding (thrombocytopenia), Bone pain, infections, masses, CNS symptoms

Lympoblasts -- ALL Diagnostic criteria? 30+% lymphoblasts in BM, Tdt+, MPO-

AML -- myeloblasts with Auer Rod, worse prognosis than ALL, allogenic Bone Marrow Transplant curative

Myeloblasts -- myeloperoxidase positive

Acute Promyelocytic Leukemia (FAB - M3) Hypergranular promyelocytes, more Auer rods, DIC from tissue thromboplastin, tx w/retinoic acid

Monoblasts -- Acute Myelogenous Leukemia (M5), nonspecific esterase

Non-specific esterase + monoblasts (left) negative control (right)

Chronic Myeloid Leukemia Features? WBC>50,000 with 80% immature, Philadelphia chromosome

Chronic Myeloid Leukemia bone marrow Clinical Course? Slow progressive and then blast phase (80%)

Essential Thrombocythemia - Bone marrow with greatly increased numbers of megakaryocytes

Myeloid metaplasia with myelofibrosis - Bone marrow fibrosis

Reactive lymphadenitis - Follicular hyperplasia

Reactive lymphadenitis - Sinus histiocytosis

Necrotizing lymphadenitis - high power

Cat Scratch Disease - Bartonella henselae bacteria

Reactive lymphocytes - Infectious Mononucleosis -- Tcells proliferate, but B cells are infected

Follicular lymphoma - lots of follicles, B cells, common in Europe and America, adults 40+yoa

Follicular lymphoma, usually diagnosed at a high stage, when bone marrow is involved, angular cells = cleaved cells

Mycosis fungoides - Sezary Syndrome, T cell lymphoma Early skin lesions (left); Skin plaques (right)

Sezary cells in blood (right); Pautrier abcess in skin (left) Mycosis Fungoides - Sezary cells in blood (right); Pautrier abcess in skin (left)

Mycosis fungoides - Sezary cells

Burkitt’s Lymphoma -- starry sky pattern due to macros Endemic type in Tropical Africa

Burkitt’s Lymphoma -- B cells, EBV associated, myc translocated t(8;14)

Hodgkins’ Disease -- cervical and mediastinal lymphadenopathy, spreads sequentially along lymph node chain, adolescents and older adults

Hodgkin’s disease -- Nodular Sclerosis type, most common subtype, dense band s of collagen/fibrosis, few Reed-Sternberg cells, young adult females

Reed-Sternberg cell -- owl eyes -- Hodgkin’s Disease

Chronic Lymphocytic Leukemia - little cytoplasm

These mature lymphocytes are increased markedly in number These mature lymphocytes are increased markedly in number. They are indicative of chronic lymphocytic leukemia, a disease most often seen in older adults. This disease responds poorly to treatment, but it is indolent.

CLL smudge cell

CLL bone marrow

Hairy cell leukemia -- single light chain expressed, (CD19 or CD20), TRAP positive, splenomegaly, pancytopenia, usually older males

Electronmicrographs of a Hairy Cell transmission EM (left); scanning EM (right)

Stained gel image Albumin Tracing of serum protein electrophoresis - Multiple Myeloma Stained gel image Albumin Tracing of serum protein electrophoresis - abnormal M spike  2 1 

Multiple Myeloma -- Rouleaux

Plasma cell myeloma, right is normal , left filled with plasma cells

Plasma cell myeloma, large cytoplasm, IL-6 mediated effects, Symptoms? Bone pain, pathologic fractures, hypercalcemia, anemia, amyloidosis

Plasma cell myeloma - lytic lesions in the skull

Plasmacytoma -- solid tumor of plasma cells, osseous usually vertebral, soft tissue usually upper respiratory tract