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Clinical Lab: Hematology


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What is hematology?
Study of:
-cellular elements in blood (RBCs, WBCs, Platelets)
-bone marrow
-diseases/disorders of the blood
Components of whole blood
Proportions of cellular elements in blood
500 RBC: 30 platelets: 1 WBC
-fluid portion of the whole blood minus the cellular elements
-composed of water, electrolytes, protein
-~55% of total blood volume
-cell fragments circulating in blood
-involved in the cellular mechanisms of primary hemostasis leading to the formation of blood clots
-produced in bone marrow
-production stimulated by thombopoietin
Hematopoiesis- where does it take place?
-begins in utero in liver and spleen until ~7 mo gestation
-bone marrow becomes major site 2 wks after birth (all bones in childrens, central skeleton proximal humeri & femurs in adults) (FLAT bones)
-liver and spleen retain hematopoiesis potential
Hematopoiesis cell line derivation
-originates with pluripotent stem cell or totipotent stem cell line in bone marrow
Lymphoid line occurs in...
-lymph nodes
Stem cell differentiates into..
committed blast cells under the influence of growth factors
Blast cells differentiate along 2 pathways:
-lymphoid line
-myeloid line (everything but lymph)
Myeloid line occurs in..
bone marrow
Components of lymphoid line:
-T cells
-B cells
Components of myeloid line
1. erythrocytes
2. leukocytes
a. Granulocytes (eosinophils, basophils, neturophils)
b. Monocytes
3. megakaryocytes
a. Platelets
Glycoprotein hormones regulate...
-proliferation/ differentation of cells in all cell lines
-maturation of cells in each cell line
-activation of each cell lines fcn
-survival of the cell line
Characteristics of glycoprotein hormones
-produced by multiple cells
-act in synergy with each other
-act on multiple cell lines
-able to act on neoplastic cells
True or Flase:
The same growth factors that cause you to produce WBCs maay cause growth in a tumor
Important growth factors
-TNF (tissue necrosing factor)
-GM-CSF (granulocyte-monocyte, colony stimulating factor)
-G-CSF (graulocyte colony stimulating factor)
Erythropoietin production is stimulated by..
-high altitude
-sleep apnea
-white blood cells
-produced in the bone marrow
-help defend body against infectious disease and foreign materials
-part of the immune system
-life span 13-20 days
-also found in large numbers in lymphatic system & spleen
Types of Leukocytes
(neutrophils, eosinophils, basophils)
(monocytes, lymphoctyes)
-polymorphonuclear leukocytes (PMNs)
-have granules and multi-lobed nuclei
Types of Granulocytes
-mononuclear leukocytes
-do not have granules
Types of agranulocytes
-WBC granulocyte
-granules do not stain
-most numerous WBC
-first line of defense for bacterial infections (phagocytes and chemotaxis)
-normally found in blood stream, but during acute phase of inflammation, esp c bacterial infection, they migrate to site of inflammation (process called chemotaxis).
-predominant cells in pus, accounting for its whitish appearance
mature neutrophils
immature neutrophils
Left shift
increase % of bands (immature neutrophils)
regenerative shift
-Elevated WBC with increase in % bands (immature neutrophils)
-GOOD bc body is winning the war (the bands are maturing faster than they are being destroyed so WBC is increasing)
degenerative shift
-low WBC with increase in % bands (immature neutrophils)
-BAD bc body is losing the battle. It does not have enough WBC and is trying to make more - but they are getting destroyed faster than they are able to mature
-may indicate sepsis
-increase in neutrophils
-acute infection
-viral/rickettsial inf
-blood dyscrasias
-liver disease
-WBC granulocyte
-stain bright reddish-orange
-granules contain histamine and proteins (eosinophil peroxidase, RNase, DNases, lipase, plasminogen, etc) that are toxic to parasites and host's tissues
-play a role in the allergic response
-play role in fibrin removal in inflammation
-persist in the circulation for 6-12 hours & survive in the tissues for another 2-3 days
-chronic skin conditions
-addisons disease
-hodgkins disease
-rheumatoid conditions
-inc adrenal stress hormones
-stressful conditions (shock, severe burns, infection)
-admin of glucocorticoids
-WBC granulocyte
-stain dark blue in Wright stain
-not phagocytic
-least common granulocyte
-contain heparin, histamine and other chemicals
-similar to mast cells
-When activated, basophils secrete histamine, several proteoglycans, lipid mediators like leukotrienes, and several cytokines (stim inflammation)
-basphilic leukemia
-chronic myelocytic leukemia
-myeloblastic crisis
-WBC agranulocyte
-large mononuclear cells
-3-4 times larger than RBCs
-phagocytic ("vacuum cleaners" of the cell)
-perform phagocytosis using intermediary (opsonising) proteins such as antibodies or complement that coat the pathogen, as well as by binding to the microbe directly via pattern-recognition receptors that recognize pathogens
- also present pieces of pathogens to T cells so that the pathogens may be recognised again and killed, or so an antibody response may be mounted
-known as macrophages after they migrate from the bloodstream and enter tissue.
Increase in monocytes with..
bacterial infections (especially in recovery stages)
-WBC agranulocytes
-second most common WBC
-Large granular lymphocytes = natural killer cells (NK cells)
-small lymphocytes = T cells & B cells
NK cells
-large lymphocyte
-part of the cell-mediated immunity
-attack host's cells that express a foreign peptide on their MHC class I surface proteins (attack cells that have been infected by microbes, but not microbes themselves)
-do not require activation in order to perform their cytotoxicity upon target cells
-Upon release in close proximity of a cell to be killed, perforin forms pores in the cell membrane of the target cell through which the granzymes and associated molecules can enter, where they induce apoptosis
-serve to contain viral infections while the adaptive immune response is generating antigen-specific cytotoxic T cells that can clear the infection.
T cells
-lymphocytes (WBC agranulocytes)
-chiefly involved with cell-mediated immunity
-"T" stands for thymus (where final development occurs)
Types of T cells
-cytotoxic T cells
-helper T cells
-regulatory T cells
-natural killer T cells
Cytotoxic T cells
-destroy virally infected cells and tumor cells
-implicated in transplant rejection
-aka CD8+ T cells
Helper T cells
-"middle men" of immune response
-once activated, divide rapidly and secrete cytokines that regulate/help immune response
-aka CD4+ cells
-target of HIV infection
Regulatory T cells
-aka suppressor T cells
-crucial in maintenance of immunological tolerance
increase in lymphocytes with...
viral infection
-cytoplasmic fragments active in plasma
-precursors are megakaryocytes
-life span 7-10 days
-assist with clot retraction
Thrombocyte function
-aggregation and adhesion lead to formation of platelet plug during intial hemostasis
-affects vascular integrity and vasocontriction (platelet derived vasoactive substances, serotonin, and platelet factor III)
-assists with clot retraction
too few platelets d/t:
-inc platelet destribution
-dec platelet production
-abnormal distribution/pooling of platelets
-consumption of platelets
Increased platelets d/t:
Abnormal platelet function may be due to..
-aspirin/NSAIDS usage (lots of aspirin may causes you to bruise easier by reducing clot formation)
-carry O2 to cells
-lifespan +/- 120 days
-consist mainly of hemoglobin (complex molecule containing heme groups whose iron atoms temporarily link to oxygen molecules in the lungs and release them throughout the body, Hemoglobin also carries some of the waste product carbon dioxide back from the tissues)
-biconcave disc without a nucleus (lack of nucleus makes capillary flow possible)
-immature RBC
-found in peripheral blood
-formation of RBC
-~5 day process to develop mature RBC
-erythropoetin secretion controlled by kidney
-hypoxia stimulates production
-produced in red bone marrow
Elements of Bone Marrow
-fat and hematopoetic elements
-adult: 10-50% fat, 40-60% cells
-kids <2: ~100% active marrow
Myeloid/erythroid ratio in bone marrow
-desired is 2:1 to 4:1
-diseased states may have inc or dec ratio
precursor for RBC
Bone Marrow aspiration common sites
-posterior iliac crest (preferred)
-spinous vertebral process
-tibia (in children)
Bone Marrow aspiration complications
-bone fracture
Clinical Indications for bone marrow aspiration
-suspicious of and dx of bone marrow infiltration or failure
-evaluate peripheral blood smear deficiency
-R/O metastatic disease or infection (eg TB)
hyperplasia (too many RBC)
hypoplasia (too few RBC)
Complete Blood Count
-one of most common ordered lab evals
-gives info about cell lines
-can identify genetic disorders in red or white cell production or fcn
-identifies anemias or deficiencies in components or RBCs
-gives clues to infection (type, condition of pt, prognosis)
Components of CBC
-RBC indices
-platelet count
-Differential (WBC)
CBC: WBC normal range
-adult: 4,500-11,000 /cu mm

-child <2: 6,000-17,000 /cu mm

-newborn: 9,000-30,000 /cu mm
Elevated WBC
-bacterial or viral infection
Decreased WBC
-viral infections
-neutropenic states
CBC: RBC normal range
-male: 4.6 - 6.2 x 10^6 /cc mm

-female: 4.2 - 5.4 x 10^6 /cc mm
Increased RBC
-polycythemia (too many cells)
Decreased RBC
CBC: Hemoglobin normal range
-male: 14-18 gm/dl

-female: 12-16 gm/dl
Hgb function
-carries oxygen to cells
-carries waste (CO2) away from cells
Decreased Hgb
-african americans
-IV fluids
Increased Hgb
-polycythemia (too many cells)
-heavy smoking
-high WBC count
CBC: hematocrit %
% of RBC mass to original volunme:
-male: 40-54%

-female: 37-47%
Decreased hematocrit
RBC, Hgb, Hct Relationships
RBC x 3 = Hgb

Hgb x 3 = Hct

RBC x 9 = Hct
Mean Corpuscular Volume

=Hct/RBC count

-measures average size of RBC
MCV normal range
82-98 fL
higher MCV

-liver disease
-megaloblastic anemia
smaller MCV

-iron deficiency
normal MCV
Mean Corpuscular Hemoglobin

=Hgb/RBC count

-average quantity (wgt) of Hgb in RBCs
MCH normal range
27-31 picograms (automated)
increased MCH
decreased MCH
normal MCH
Mean Corpuscular Hemoglobin Concentration


-concentration of Hgb in an average RBC
MCHC normal range
31-37% (automated)
-RBC Distrubution Width

-RBCs sorted according to size
RDW normal range
What changes may be reflected in RDW?
anemia changes
(may be reflected here before reflected in MCV)
Smaller RDW =
greater uniformity in cell size
Larger RDW=
less uniformity in cell size
Mean Platelet Volume
average size of the platelets
relationship between MPV and total platelet count
inverse relationship
platelet count normal range
150,000-400,000/cc mm
Increased MPV??
-idiopathic thrombocytopenic pupura
-myloproliferative disorders
Decreased MPV??
Typically, the more platelets you have....
...the smaller the platelets tend to be
Automated differentials
-based on size and density of cells
-often 3 parts: lymphs, monos, segs
-cannot differentiate:
segs from bands
monos from ATLs
-may not give counts on basophils or eosinophils
Manual differentials
-hand count of 100 WBCs in peripheral blood
-provides RBC morphology
-gives estimate of platelet size and number
-identifies other patient or specimen problems
Differential Ranges (as % of WBCs):
Differential Ranges (as % of WBCs):
Differential Ranges (as % of WBCs):
Differential Ranges (as % of WBCs):
Differential Ranges (as % of WBCs):
Absolute count
relative value (cell%) x total WBC count
Neutrophil Left Shift
>10% bands OR differential with >80% neutrophils

-inc in number of bands of neutrophils
Neutrophil left shift suggests:
-infection (usually bacterial)
-drug rxn
neutrophil left shift -
inc in % of bands and inc in WBC count
Neutrophil left shift -
inc in % of bands and low WBC count
Neutrophil right shift
-inc in number of mature neutrophils
Neutrophil right shift suggests:
-megaloblastic or iron deficiency anemia
-liver disease
WBC differential: Bacterial
Bands: inc
Segs: inc
Lymphs: dec
Monos: inc or norm
Eos: norm
Basophils: norm
WBC differential: Viral
Bands: norm
Segs: dec
Lymphs: inc
Monos: norm
Eos: norm
Basophils:: norm
Bacterial vs viral WBC differential:
Bacterial: inc

Viral: norm
Bacterial vs viral WBC differential
Bacterial: inc

Viral: dec
Bacterial vs viral WBC differential
Bacterial: dec

Viral: inc
Bacterial vs viral WBC differential
Bacterial: inc or norm

Viral: norm
Bacterial vs viral WBC differential
Bacterial: norm

Viral: norm
Bacterial vs viral WBC differential
Bacterial: norm

Viral: norm
Quantitative Leukocyte Disorder
Qualitative Leukocyte Disorder
-problems with cell function
(normal counts, but cells dont work)
-disorders of chemotaxis (congenital or aquired)
-disorders of phagocytosis
(often d/t hypogammaglobulinemia)
-disorders of killing and digestion (chronic greanulomatous disease)
Leukocytosis values:
>10,000/cu mm

panic value: >30,000/cu mm
(leukemia or leukemoid)
Leukocytosis differential:
-acute infection or inflammation
-trauma or tissue necrosis
-leukemias or other neoplastic disorders
-acute hemolysis or hemorrhage
Luekocytopenia values:
< 4,000 cu/mm

panic value: <500/cu mm
Leukocytopenia differential:
-infection: viral suppression or bacterial sepsis
-nutritional deficiencies (Fe)
-Bone Marrow suppression
-acute infection
-inflammatory rxn
-acute hemorrhage or hemolysis
-myloproliferative disorder
-tissue necrosis/burns
-acute phase infection
Decreased Monocytes
-prednisone therapy
Increased Monocytes
-bacterial infections (esp recovery stages)
-recovery from infections
-ulcerative colitis
-collagen vascular disease
Decreased Lymphoctyes
-GI loss
-Aplastic anemia
-Severe illness
-Rheumatic fever
Increased Lymphocytes
-serum sickness
-hypersensitivity rxns
Toxic Granulations
-severe illnesses (burns, sepsis, high fever)
Dohle Bodies
-severe infection, burns, malignancy pregnancy
Auer Rods
-acute myelogenous leukemia (AML)
Hypersegmented Nuclei
-megaloblastic anemia!!!
Leukomoid Rxn
-non-leukemic rise in WBC count
Leukomoid Rxn range
50-100,000/ cu mm

>5% metamyelocytes or other early cells
Causes of Leukomoid Rxn
-severe bacterial infections
-severe toxic states (burns, necrosis)
- extensive tumor infiltration of bone marrow
-severe hemolytic anemia/severe blood loss
-JRA (juvenile RA)
-immature WBCs and RBCs on the peripheral smear
Causes of leuko-eryhtro blastosis
-40% myeloid metaplasia, polycythemia vera, hemolytic anemia
-25-30% metastaic bone marrow tumore
-20% leukemia
-10% severe infection
-5-15% noneoplastic

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