Hematopathology Lab 1 Normal blood smear

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Hematopathology Lab 1 Normal blood smear

Learn, Keith, Host has reference to this Academic Journal, PHwiki organized this Journal Hematopathology Lab 1 Start Slide Show Read history, review image stacks (space bar, arrow, mouse click) Space bar, arrow, mouse click to reveal question Space bar, arrow, mouse click to reveal answers After working through case using PPS, open virtual slide (links in PPS) in addition to review Your instructor will briefly introduce each case then ask students to work through the slides, questions, answers in addition to virtual slides using the PowerPoint show (PPS) on their laptops. The micrographs are displayed adjacent to micrographs of a “normal” or “look-alike” abnormal smear at the same (or nearly the same, case 3) magnification. The micrographs should serve as a guide as long as viewing the virtual slides. The virtual slides can be accessed from links embedded in the PPS (if you are using a workstation or laptop on the Medical School Campus). A “self-test tool” as long as the virtual slides is available as well (self-test tool). Normal blood smear Virtual Slide Normal Smear (Web viewer) CASE 1: A 19-year-old woman with anemia presents with a two day history of fever in addition to joint pain. She reports experiencing similar episodes 2-3 times/year that respond to hydration in addition to pain medication. Her history is notable as long as avascular necrosis of the left femoral head at age 14. Normal smear stack Patient stack Virtual Slide Normal Smear (Web viewer) Virtual Slide Patient Smear (Web viewer)

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CASE 1: A 19-year-old woman with anemia presents with a two day history of fever in addition to joint pain. She reports experiencing similar episodes 2-3 times/year that respond to hydration in addition to pain medication. Her history is notable as long as avascular necrosis of the left femoral head at age 14. What are the major RBC abnormalities on the smear Many sickle cells in addition to some polychromasia (young RBCs; nucleic acid stains blue, protein red with Wright stain). Marked variability in red cell shape (poikilocytosis), a few target cells in addition to occasional RBC with small, dark blue inclusions (Howell-Jolly bodies, nuclear fragments) indicate splenic hypofunction from repeated infarcts (“autosplenectomy”). Occasional activated lymphs ( viral infection triggered sickle crisis). A diagnosis of the “process” is readily made by inspection of the smear. What additional test(s) establish etiology A patient with multiple sickle crises/year is likely to have a moderate-severe as long as m of the disease in addition to , most likely, would have been diagnosed in infancy or childhood. Hemoglobin electrophoresis establishes a diagnosis in most cases. What would you expect the red cell indices to show in this case Generally normochromic in addition to normocytic. If you just had the CBC in addition to red blood cell indices, what other types of anemia would you consider Differential diagnosis of a normochromic, normocytic anemia includes decreased red blood cell production (e.g., aplastic anemia, some cases of anemia of chronic disease), acute (uncompensated) blood loss, other hemolytic anemias. How do the abnormal RBC produce symptoms, signs in addition to complications in this disease Sickled cells are stickier in addition to stiffer than normal RBCs thus “adhere” to endothelium, to one another in addition to to WBCs, particularly in post-capillary venules, producing thrombosis. During “painful crises” (triggered by hypoxia, infection), sickled fraction increases resulting in thromboses in many microvascular beds. Ischemia in addition to infarction ensues with cumulative organ damage in multiple organs. CASE 2: The patient is a 28-year-old woman in the second trimester of pregnancy. Her pregnancy has been uncomplicated but she tires easily in addition to gets short of breath with exertion. She reports episodes of light-headedness, though not to the point of fainting. Patient has tachycardia at rest, pale gums in addition to nail beds. Normal smear stack Patient stack Virtual Slide Normal Smear (Web viewer) Virtual Slide Patient Smear (Web viewer) CASE 2: The patient is a 28-year-old woman in the second trimester of pregnancy. Her pregnancy has been uncomplicated but she tires easily in addition to gets short of breath with exertion. She reports episodes of light-headedness, though not to the point of fainting. Patient has tachycardia at rest, pale gums in addition to nail beds. What are the major RBC abnormalities on the smear Hypochromia, anisocytosis, microcytosis in addition to poikilocytosis. A diagnosis of the “process” is readily made by inspection of the smear. What additional test(s) establish etiology Serum ferritin, iron in addition to iron-binding capacity to confirm iron deficiency anemia (IDA). If IDA confirmed still need to establish cause. Insufficient intake most common cause in healthy pregnant women but want to rule out occult blood loss. What would you expect the red cell indices to show in this case Hypochromic, microcytic anemia. If you just had the CBC in addition to red blood cell indices, what other types of anemia would you consider Differential diagnosis of microcytic, hypochromic anemia includes iron deficiency, thalassemias, anemia of chronic disease/inflammation, in addition to lead poisoning. How do the morphologic in addition to biochemical abnormalities produce symptoms, signs in addition to complications in this disease Reduced oxygen carrying capacity. Fatigue, tachycardia, shortness of breath, pale gums in addition to nail beds. Occasionally, bizarre appetites as long as substances that are largely non-nutritive (e.g., clay, soil, s in addition to , paper, ice), termed pica.

CASE 3: A 50-year-old woman with a history of Type II diabetes mellitus, hypertension, in addition to chronic obstructive pulmonary disease felt well until 4 days prior to hospitalization when she developed crampy abdominal pain in addition to deteriorating mental status. There was no prior history of a hematologic disorder. Normal smear stack Patient stack CASE 3: A 50-year-old woman with a history of Type II diabetes mellitus, hypertension, in addition to chronic obstructive pulmonary disease felt well until 4 days prior to hospitalization when she developed crampy abdominal pain in addition to deteriorating mental status. There was no prior history of a hematologic disorder. What are the major RBC abnormalities on the smear Substantial poikilocytosis including many schistocytes, occasional spherocytes, in addition to some polychromasia. This constellation of microangiopathic features was found in the context of profound thrombocytopenia. A diagnosis of the “process” is readily made by inspection of the smear. What additional tests may help to confirm the morphologic impression in addition to subclassify this process Measurements of serum lactate dehydrogenase (LDH), unconjugated bilirubin, in addition to haptoglobin help to confirm the impression of microangiopathic hemolytic anemia (MAHA). Screening coagulation assays (e.g., prothrombin time, activated partial thromboplastin time) in addition to other tests (e.g., ADAMTS13 level) can help to refine the diagnosis (e.g., discriminate disseminated intravascular coagulation (DIC) from thrombotic thrombocytopenic purpura (TTP)). What would you expect the red cell indices to show in this case Generally normocytic in addition to normochromic. What is the physical basis as long as the observed red cell morphology Shear stress or mechanical trauma disrupts the red cell membrane, resulting in as long as mation of red cell fragments (schistocytes in addition to microspherocytes). There is laboratory evidence of intravascular hemolysis as red cells are damaged by contact with fibrin/platelet aggregates. The polychromasia reflects compensatory reticulocytosis. Disorders commonly associated with fragmentation hemolysis include DIC, TTP, in addition to hemolytic uremic syndrome (HUS). Prosthetic cardiac valves in addition to areas of highly turbulent flow (e.g., severe aortic stenosis) sometimes cause shear stress on red cells resulting in schistocyte as long as mation. SUMMARY AND REVIEW MECHANISTIC CLASSIFICATION OF ANEMIA Blood Loss Examples: – Acute – trauma; surgery – Chronic – lesions of GI or GU tracts II. Increased RBC destruction (hemolytic anemias) Examples: – Hereditary – hemoglobinopathies; RBC membrane or enzymatic defects – Acquired – autoimmune hemolysis; mechanical trauma to red cells Impaired RBC production Examples: – Aplastic anemia – Defective DNA synthesis (B12/folate) – Defective heme synthesis (iron) REMEMBER THE UTILITY OF THE RETICULOCYTE COUNT IN DISCRIMINATING THESE CATEGORIES !

SUMMARY AND REVIEW CLASSIFICATION OF ANEMIA ACCORDING TO MEAN CELL VOLUME (MCV) MICROCYTIC Examples: iron deficiency; thalassemia; some cases of anemia of chronic disease/chronic inflammation II. NORMOCYTIC Examples: sickle cell anemia; hereditary spherocytosis; some cases of anemia of chronic disease/chronic inflammation; some cases of hemolytic anemia MACROCYTIC Examples: vitamin B12 or folic acid deficiency (megaloblastic anemias); liver disease; hypothyroidism; some cases of hemolytic anemia (e.g., those with a particularly prominent reticulocytosis; reticulocytes are slightly larger than more mature red cells, on average, in addition to will raise the MCV)

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