WBC Diseases and Disorders

What are the two groups of Neutrophils in PB

Circulating neutrophils

Marginating neutrophils

What are the 3 types of granules

Primary – first to appear
• Secondary – appear next
• Tertiary – last to appear

Which granules are stain with Wright’s stain

Primary

Secondary

What are the characteristics of Primary Granules

Contain myeloperoxidase

Formed abundantly in promyelocyte

Small number of primary granules are present in
neutrophil

Purpose is to activate proteinases to kill bacteria
Also called azurophilic or non-specific

What are the characteristics of Secondary Granules

Are the specific granules
• Appear first in the myelocyte

Contain lysozymes and other enzymes

What are acute disorders?

Associated more with leukemia
• Younger cells are observed
• Progression is faster and prognosis is usually worse
• Usually associated with younger individuals

What is chronic disorder?

Contains more mature cells
• Slower progression
• Usually associated with older individuals

What are the Myeloproliferative
Disorders?

Clonal hematopoietic stem cell diseases with expansion,
excessive production, and over-accumulation of cells
• Erythrocytes
• Granulocytes
• Platelets
• Usually chronic with accelerated, subacute, or acute phases

What disorders are included with Chronic Myeloproliferative
Disorders (MPD)

Chronic myelogenous leukemia (CML)
• Polycythemia vera (PV)
• Essential Thrombocythemia (ET)
• Primary Myelofibrosis (PMF)

What age group is mostly affected by Chronic Myeloproliferative
Disorders

Primarily middle aged and older

What are the symptoms of Chronic Myeloproliferative
Disorders

Fatigue, anorexia
• Splenomegaly
• Bone pain
• Vague or variable symptoms

What is the lab finding of MPD

Anemia
• Normocytic, normochromic
• Anemia is NOT observed in Polycythemia
• Leukopenia
• Increased infections
• Bone marrow
• Hypercellular with no fat
• Opposite from aplastic anemia

What can cause MPD

Most are due to a mutation of a single multipotential or
pluripotential stem cell
• Cell abnormally proliferates
• Fibrosis occurs secondarily
• Most often due to exposure to radiation or toxins
• Benzene, toluene, arsenic, lead, and fluorine

What are the lab findings for Myelofibrosis

Normocytic, normochromic (NC,NC) anemia
• Dacrocytes (tear-drop cells)
• Nucleated RBCs
• Rubricytes and metarubricytes
• Immature granulocytes
• May observe a few blasts

What kind of treatment is needed for Myelofibrosis

Use chemotherapy, splenectomy, and support
• Blood transfusions are common
• Stem cell transplants are having success

What can cause CML

Usually due to a chromosome disorder
• Philadelphia chromosome

What is the lab finding for CML

Extreme leukocytosis
• WBC > 100,000/uL
• Severe left shift
• <5% blasts
• Mostly myelocytes
• Increased or high normal platelet count
• Increased basophils and eosinophils
• Bone marrow is hypercellular
• M:E ratio 20:1

. Low Lap scocre

What is Leukocyte Alkaline Phosphatase
(LAP)

Alkaline phosphatase located in specific granules
• Used to distinguish between
• Leukemoid reaction

What treatment is use for CML

Use chemotherapy, transplantation, and
leukopheresis (remove WBCs)

Polycythemia Vera

Stem cell disorder that affects all three cell lines

What are the symptoms of PV

headache, abdominal pain, ruddy
complexion, and hypertension

What is the lab finding for PV

Increased RBCs cause increased blood viscosity
• Increased risk of stroke, heart attack
• Increased platelet count can cause thrombosis
• PV will have increase in all cell lines
• Decreased erythropoietin levels

Increased hemoglobin – similar to newborn
• Males >18.5 gm/dL
• Females >16.5 gm/dL
• Increased RBC, WBC, platelets
• RBC often >7 million/uL
• Left shift and occasional NRBC
• Increased RBC mass

Essential Thrombocythemia

Clonal disorder of platelets involving a single
multipotential stem cell

What are the lab findings for Essential Thrombocythemia

High platelet count
(>1,000,000/uL)
• Huge and bizarre forms
observed
• Micromegakaryocyte and
bare nuclei present on
peripheral blood
• Increased WBC with left
shift
• NC/NC anemia is most
common finding

What is the treatment for Essential Thrombocythemia

Use immunosuppressive drugs
• Radioactive phosphorus
• Patients may survive for years

What the difference between leukemia and lymphoma

Leukemia starts in the bone marrow and spreads through the blood into the RES

Lymphomas begin in the lymph nodes

Is ALL more common in children

yes

Is AML more common in Adult

yes

What are the symptoms of AML

Decreased platelets cause bruising and bleeding
• Decreased RBC cause fatigue, pallor, shortness of breath
• Bone pain from marrow expansion

What does AML look like in blood

WBC is decreased, normal or increased

Platelets are decreased

NC/NC anemia

Immature cells

What are the lab findings of AML in bone marrow

>30% blasts for acute FAB

Marrow is hypercellular with little fat

WHO criteria says >20% blasts with chromosomal
abnormalities

Presence of Auer Rods
is hallmark
• Fusion or bundles of
primary granules

• Indicate AML, AMML, or
AMoL

Which of the following patterns is characteristic of the peripheral blood in patients with primary myelofibrosis?

Tear drop-shaped erythrocytes, nucleated RBCs, immature granulocytes

A patient has a platelet count of 700 x 10³ per microliter, with abnormalities in size, shape, granularity of platelets; a WBC count of 12 x 10³ per microliter, and hemoglobin of 11 g/dL. The Philadelphia chromosome is not present. What is the likely diagnosis?

Essential Thrombocythemia

The most common mutation found in patients with polycythemia vera (PCV) is:

JAK2 V617F

What abnormal chromosomal is 20% counted in AML

t(8;21), inv(16), t(15;17)

What is the FAB CLASSIFICATION for ALL L1

small, uniform lymphoblasts
• Scant cytoplasm
• Inconspicuous nucleoli
• Most common of ALL
• Pediatric age group – best prognosis
• B cell lineage – may be t(12;21)

What is the FAB CLASSIFICATION for ALL L2

Large, pleomorphic lymphoblasts
• More abundant cytoplasm
• Less condensed nuclei
• More conspicuous nucleoli
• Cells often have indented nucleus
• Often found in over age 15
• B or T cell lineage

What is the FAB CLASSIFICATION for ALL L3

Burkitt’s type leukemia
• Cells are vacuolated with abundant, deeply basophilic cytoplasm
• Represents the leukemic phase of Burkitt lymphoma
• Leukemic B cells
• BCL-2 (B-cell lymphoma protein) is absent so cells rapidly proliferate
• Worse prognosis

What are the lab findings of ALL

WBC – low, normal or high
Anemia is often severe
• Decreased platelet count, often severe
• Bone marrow is hypercellular with lymphoblasts
• M:E ratio is normal

What is the FAB CLASSIFICATION for AML M0

No definitive myeloid differentiation
• Blasts lack myeloid morphologic features
• Negative Myeloperoxidase and Sudan Black B
• Auer Rods not seen

What is the FAB CLASSIFICATION for AML M1

Myeloblastic without maturation
• 90% of cells are primarily blasts
• Fewer than 10% of leukocytes show maturation to the promyelocyte
stage of beyond
• Auer rods may be seen
• Bundles of primary granules that stain purple on Wright-Giemsa stain
• Worst to have

Which cytochemical stains is M1 AML pos for

Myeloperoxidase
• Sudan Black
• Specific esterase

What is the FAB CLASSIFICATION for AML M2

Chromosome abnormality t(8;21)

Greater than 20% Blasts
• Maturation beyond promyelocyte in marrow
• At least 10% maturing cells of neutrophil lineage.
• Better prognosis with mature cells
• Auer Rods present

What is the FAB CLASSIFICATION for AML M3

Chromosome abnormality t(15;17)

Majority of cells are promyelocytes with large granules
• Auer rods in bundles are prominent
• Peroxidase and Sudan Black B positive
• DIC (clotting disorder) often occurs
• Fatal complication

(PROMYELOBLASTIC)

What is the FAB CLASSIFICATION for AML M4 (Naegli)

Cells have features of monocytes and immature
granulocytes
• Myeloblasts and monoblasts are present
• Specific and non-specific esterase are positive
• Positive lysozyme (muramidase) in urine and blood
• Bacteriologic Enzyme found in granulocytes and monocytes
• Represents increased cell turnover/degradation
• As seen in malignant processes, such as AML

M4EO is associated with chromosome abnormality [inv(16)]

What is the FAB CLASSIFICATION for AML M5

Monocytic (Schilling Leukemia)

> 80% of bone marrow cells are of monocytic
orgin
• High prevalence of extramedullary tumors
• Especially gums
• Gums bleed
• Present with high WBC
• Positive non-specific esterase
• Alpha-napthyl acetate butyrate esterase
• Negative Specific Esterase
• Positive lysozyme (muramidase)
• Hydrolytic enzyme found in monocytes

What is the FAB CLASSIFICATION for AML M6

Erythroleukemia (DiGuglielmo’s)

NRBC and Myeloblasts in peripheral
• > 50% of nucleated bone marrow cells are normoblasts
• And >20% myeloblasts
• BM shows red cell hyperplasia
• Bizarre forms including dysplasia, multi-nucleated, nuclear
budding, and giant forms
• Differentiate between
• Megaloblastic – karyorrhexis (B12, folate)
• Myelodysplastic syndrome - PV

What is the FAB CLASSIFICATION for AML M7

Megakaryoblast

Very rare
• Platelet peroxidase (PPO) is specific
• Related to myelofibrosis
• Dry tap due to fibrosis
• Blasts have abundant budding cytoplasm
• Platelet count is normal or high

What are the names for all of the CYTOCHEMICAL STAINS

Myeloperoxidase

Sudan Black B

Esterases

Naphthol AS-D Chloroacetate

Alpha-naphthyl acetate or butyrate

Periodic Acid-Schiff (PAS)

What are the characteristics of
Myeloperoxidase

• Useful in differentiating blast in AMLs from ALL blasts
• Enzyme found in Primary granules of myeloid cells
• Leukemic myeloblasts are positive for MPO
• The fact that maturing granulocytes are MPO positive is normal,
and has little or no diagnostic difference

What are the characteristics of Sudan Black B

Useful in differentiating AML from ALL
• Phospholipids, neutral fats, sterols
• Primary and secondary granules
• Myeloblast through maturation stages
• Staining becomes more intense as the cell matures

What are the characteristics of Esterases

Used to differentiate myeloblasts and neutrophilic granulocytes
from cells of monocytic origin

What are the characteristics of Naphthol AS-D Chloroacetate

Specific Esterase (SPE)
• Myeloid Cells

What are the characteristics of Alpha-naphthyl acetate or butyrate

Non-specific esterase (NSE)
• Monocytes (erythroid & megakaryocytic)
• Butyrate most specific for monocytes
• Acetate is more sensitive

What are the characteristics of Periodic Acid-Schiff (PAS)

Stains glycogen and related compounds
• Positive in lymphocytes, segmented neutrophils and nucleated red
cells
• Helpful in diagnosing erythroleukemia