vis dis WBC and blood cancer

WBCs/leukocytes

form the first line of defense of the body from invading microorganisms, during infections and inflammatory processes, changes in these cells directly or indirectly reflect the patient’s condition - HAVE a nucleus

granulocytes

cells that contain granules - neutrophils, eosinophils, and basophils - production begins in bone marrow and is under the influence of growth hormone it takes about 14 days from blast stage to release of the mature granulocytes into peripheral blood - all 3 have similar maturation process

nongranulocytes

lymphocytes and monocytes

leukopoiesis

process by which WBCs differentiate and proliferate - development occurs primarily within bone marrow with the exception of lymphocytes which can take place in the bone marrow and thymus - leukoctyes are divided by function, site of origin and morphology

shift to the left

when there is an increase in immature cells - also called a shilling shift - more metamyelocytes, myelocytes, promyelocytes, blasts, and bands

neutrophils

contain acid phosphatase, acid hydrolase, peroxidase - first line of defense due to phagocytic action and combat pyogenic infections - also called segs because they are segmented cells as the nucleus has 2-5 lobes - also removes damaged or dead cells and cellular debris through phagocytosis

eosinophils

contain proteolytic enzymes (histamines) that aid in ingestion of parasites and limits allergic reactions - primarily a tissue cell and not common in blood - often associated with hypersensitivity reactions - eosinophilia seen with asthma, rhinitis, hay fever, parasitic infection, Hodgkin’s lymphoma

basophils

contain histamine and heparin - function in immediate hypersensitivity reactions by release of histamine and heparin and also combats parasites

lymphocytes

function to fight viral infections (measles, rubella, chickenpox, mononucleosis) - antigen recognition and immune response (elimination) - lymphocyte precursors mature in bone marrow then migrate to extramedullary sites - produce antibodies

monocytes

function is to help neutrophils - present in recovery phase of infection and is a favorable sign - function as a scavenger and phagoctysosis of dead or dying cells, bacteria, fungi, and viruses - process specific antigens for the lymphocyte - circulate only a short time and then enters tissues as a macrophage to further differentiate - produces lysosomes, thromboplastin, platelet activating factor

normal white blood cell count

adult is 5-10,000, children is 4-11,000, 6 months to 1 year old is 6-14,000, 0-6 months old is 6-18,000

leukocytosis

increase in total WBCs - type based off of what cell is elevated (neutrophilia, eosinophilia, lymphocytosis, monocytosis, basophilia)

leukopenia

decrease in total WBCs, less than 5,000

what could leukocytosis indicate?

infection, inflammation, tissue necrosis, stress, strenuous exercise, drugs (corticosteroids, lithium, beta agonists), trauma (splenectomy), leukemoid reactions, leukemia, bacterial infections 10-18,000, appendicitis 10-18,000, mononucleosis late stage 10-18,000, acute abdomen 20-30,000 (peritonitis)

leukopenia can indicate what?

viral infections, overwhelming bacterial infections, and bone marrow disorders - also antibiotics

fever with high WBC count (10-18) usually indicates what?

bacterial infection

low to moderate fever with decrease (leukopenia) in WBCs usually indicates what?

viral infection (antibiotics do the same)

some differentials for hot abdomen

appendicitis, diverticulitis, pancreatitis

are bacterial or viral infections generally wrose?

bacterial infections

EX patient presents with difficulty breathing, chest pain, opacification in lung fields with a white count of 3800, consider

viral pneumonia

order of how many types of WBCs should be in a count

neutrophils, lymphocytes, monocytes, eosinophils, basophils, bands

leukomoid reaction

between 30-50,000 - mimics chronic myelocytic leukemia - is due to overwhelming bacterial infections - bone marrow findings and philadelphia chromosome are negative unlike CML and a shift to the left is observed

leukemia

typically greater then 50,000 WBC count

absolute WBC count

multiple the differential count by total WBC count - ALC = WBC x % lymphocytes

stem cell theory

all cells arise from stem cells - if one cell type increases, others decrease

neutrophilia

usually due to bacterial infections - may also be due to inflammation, tissue destruction may also be increased after severe exercises, stress and hypoxia, myelogenous leukemia (acute or chronic), and leukemoid reaction

toxic granules (from neutrophils)

seen with infections, burns, malignancy, and chemical poisoning

toxic vacuoles (with nuterophils)

seen with septicemia, severe infections and toxic states, sign of degeneration

hyper-segmented neutrophils are seen with what kind of anemia?

megaloblastic anemia

B lymphocytes

tag foreign bodies and are part of antibody production - mature in bone marrow and then released to lymph nodes, spleen, lymphoid tissue - ultimately matures into a plasma cell - humoral immunity

T lymphocytes

kill foreign bodies (tumor suppression, protect intracellular organisms) - migrate to thymus to proliferate T helper and T suppressor cells then migrate to lymphoid tissue and represent the majority of lymphoid cells -cellular immunity

natural killer cells

cytotoxic lymphocyte within the innate immune system slide

lymphophilia

increase in lymphocytes usually due to viral infections (and some chronic bacterial)

lymphocytes in children

inverted ratio is normal up till age 9, so there being more lymphocytes than neutrophils in young kids is normal while they are developing immunity in first years of life

inverted ratio

lymphocytes are more numerous than neutrophils - can be seen in viral infections, lymphocytic leukemia, lymphocytic leukemoid reactions, and those under 9 years old

what scenarios is lymphopenia (decreased lymphocytes) seen in?

AIDS, Hodgkin’s, and most commonly bacterial infections

atypical lymphocytes

also called reactive lymphocytes - downey cells, virocytes represent nonfunctional cells seen with viruses (mononucleosis is classic) - T lymphocyte in a state of immune activation

relative lymphocytosis

normal WBC with an increased percentage of lymphocytes due to viral infections such as rubella, varicella, and mumps

absolute lymphocytosis

elevated WBCs with an increase in lymphocyte count due to viruses

mononucleosis (lymphocytosis)

infection due to epstein-barr virus seen in adolescents and young adults - vague onset of fever, sore throat, neck pain, fatigue, splenomegaly, lymphadenopathy, and headache - early in infection (1st few days) WBCs are reduced like a virus then leukocytes are increased and most are lymphocytes (increased atypical lymphocytes) - leukocyte count returns to normal in a few weeks - serologic testing with monospot (heterophil AB)

HIV/AIDS (lymphocytopenia)

infection due to human immunodeficiency viruses spread by contamination with secretions, blood, excretions and infected tissues - marked decrease in T-helper cells (# of T helper cells determined by the CD4 count) - profound cellular immunity depression - opportunistic infections like kaposi’s sarcoma and pneumocytosis pneumonia a fungal pneumonia) - hematology reveals ACD, lymphopenia, neutropenia, and thrombocytopenia

CD4 count

like a snapshot of how well your immune system is functioning - the more CD4 cells you have, the better as these are cells that HIV kills - when this drops below 200 due to advanced HIV disease, a person is diagnosed with AIDS - normal range is 600-1500

viral load

measures the amount of HIV in the blood - lower levels are better - determines how rapidly HIV is progressing

kaposi sarcoma

cancer that develops from cells that line lymph or blood vessels - the abnormal cells form purple, red, or brown blotches or tumors on the skin

reed sternburg cells are diagnostic of what?

Hodgkin’s lymphoma - from lymph node biopsy

leukemia

unregulated accumulation of immature cells in the marrow and lymph tissue (typically greater than 50,000 WBCs) - demonstrate neoplastic formation with a left shift - chronic form is slightly more common than acute - should be classified as lymphocytic and non-lymphocytic (myelocytic) and then further classified based on predominate cell type - slightly higher incidence rates among males

generalized signs and symptoms of leukemia

weakness, fatigue, weight loss, bleeding from any orifice, splenomegaly, hepatomegaly, back pain, lymphadenopathy, symptoms similar to infection

acute leukemia

rapid onset of a few weeks and the more severe form - AML demonstrates proliferation of myeloblasts, promyelocytes (primitive cells) (WHO >20%) - ALL demonstrates proliferation of lymphoblasts and prolymphocytes (WHO < 20%) - without remission is usually fatal within 3 months

extra signs and symptoms seen with acute leukemia

abnormal bleeding (spontaneous nose bleeds, bleeding gums, blood in urine and stool), easy bruising, multiple joint pain, progressive pallor and weakness, swollen lymph nodes, low grade fever, and hepatosplenomegaly (immature cells are non-functional and the body gets rid of them)

chronic leukemia

similar signs and symptoms of Acute but they develop over months - CML demonstrates proliferation of myelocytes, metamyelocytes, and neutrophils and bands (LACK of blasts and pros) (WHO <20%) - CLL demonstrates more small mature lymphocytes - without remission, will survive years

acute myelocytic leukemia (acute granulocytic or acute non-lymphocytic leukemia)

most common in middle and later years (>50 years, slightly higher in males) - most common acute leukemia found in first few months of life (rare in childhood and adolescents) - onset may resemble an acute infection and is rapidly progressive - median age is 69 years - marked increase of WBCs with proliferation of primitive cells - blasts and pros present (WHO >20%, FAB says >30) - predominately neutrophilic involvement

what types of acute leukemia are rare?

acute monocytic leukemia AMoL and acute eosinophilic leukemia AEL and acute stem cell leukemia

what type of acute leukemia is extremely rare?

acute basophilic leukemia ABL

acute lymphocytic anemia (lymphoblastic leukemia)

characterized by a large number of lymphoblasts and prolymphocytes (L pros) - 95% are seen in patients les than 20 years old - rapid onset, fatigue, fever, bleeding, infection, lymphadenopathy, hepatosplenomegaly - identified as L blasts and L pros on a differential

what radiographic finding would you see in a young patient with leukemia?

radiolucent submetaphyseal band - called scorbutic zone

chronic myelocytic leukemia

accounts for 20% of total leukemias and 20% are asymptomatic - most common in the middle age and later years especially after 65 (median age is 66), more common in males - gradual onset with hepatosplenomegaly - low alkaline phosphatase levels - should be differentiated form neutrophilic leukemoid reaction and has a worse prognosis than CLL

philadelphia chromosome Ph1

can be identified in 90% of CML patients - this results from deletion of the long arm of the G-22 chromosome - patients with this have a better prognosis

symptoms of chronic myelocytic leukemia

likely to see anemia of chronic blood loss here - abdominal discomfort, weight loss, anemia, weakness, fatigue, later may have easy bruising, bleeding, lymphadenopathy

chronic lymphocytic leukemia

results from proliferation of long lived non-functional lymphocytes - most patients are diagnosed from routine peripheral blood studies - 30% of all cases of leukemia - commonly seen in patients over 50, particularly ages 60-70 , men more than women - will see lymphadenopathy and hepatosplenomegaly - insidious onset - should be differentiated from lymphocytic leukemoid reaction

symptoms of chronic lymphocytic leukemia

fatigue, weight loss, abdominal fullness, anemia of chronic disease, increased susceptibility to infections

chronic lymphocytic leukemia labs

high white count predominately lymphocytes, anemia, thrombocytopenia (bleeding issues, bruising), and granulocytopenia - lymphocytic infiltration of bone marrow, lymph nodes, liver, spleen, and other organs

leukemoid reaction

elevated white blood cell count (leukocytosis) that is a physiological response to stress or infection (as opposed to a primary blood malignancy like leukemia)

neutrophilic leukemoid reaction (myelocytic leukemoid reaction)

mimics CML (tests for leukemia are negative - no philadelphia chromosome and bone marrow findings are normal) - characterized by neutrophils with a left shift - 20/30-50 range so normal to elevated leukocyte alkaline phosphatase levels (decreased in CML)

myelocytic leukemoid reactions

neutrophil leukemoid reaction (MC), eosinophilic leukemoid reaction, basophilic leukemoid reaction, monocytic leukemoid reaction

lymphocytic leukemoid reaction

characterized by lymphocytosis (more lymphs than segs) - mimics CLL - typically less than 50,000/cubic mm seen with severe viral infections - absence of lymphocytic leukemia cells in bone marrow and negative lymph nodes - evidence of the primary infection

lymphoid disorders

lymphocytes are a group of malignant disorders that originate from unregulated lymphoid tissue growth - when neoplastic cells involve predominately the blood and bone marrow, it is termed leukemia - when the condition is predominantly limited to lymph nodes and/or organs then it’s termed lymphoma - early sign is painless enlargement of one or more lymph nodes

signs and symptoms of cancer

painless, swollen lymph nodes in the neck, chest, armpit, groin, or spleen - sweating and/or fever (especially at night), abnormal tiredness, weight loss, loss of appetite, persistent itching, persistent cough, persistent breathlessness, pain in the lymph nodes after drinking alcohol

stage I lymphoma

disease is limited to one set of lymph nodes

stage II lymphoma

more than one site is involved, although only on one side of the diaphragm

stage III lymphoma

lymph tissue or spleen on both sides of the diaphragm is involved

stage IV lymphoma

other/multiple organ involvement, bone marrow, and liver

reed-sternberg cells are associated with what kind of lymphoma?

hodgkin’s lymphoma

hodgkin lymphoma

malignancy derived from lymphoid tissue, primarily lymph node tissue and bone, especially involves B cells - reed-sternberg cells are hallmark - early childhood to old age with a male predominance - increased frequency in those between 15 and 35 and then after 50 (bimodal) - diagnosis is with lymph node biopsy - painless enlarged lymph node usually in the neck, night sweats, low grade fever, and weight loss, itching, blood findings, neutrophilia, monocytosis - associated with epstein-barr virus

non-hodgkin lymphoma

malignancy derived from lymphoid tissue including lymph node tissue, spleen, liver, GI tract, bone, may involve B cells primarily and T cells (damage to the DNA is acquired rather than inherited) - occurs in all ages and incidence increases with age and has male predominance - non-contiguous spread - painless enlarged lymph nodes, especially cervical, extranodal GI, skin, lungs - normal blood findings

the 5 T’s

thymoma, teratoma, thyroid (goiter), terrible lymphoma (HL and NHL), thoracic aneurysm

what does it mean if there is calcium in a mass that’s in the chest?

it’s most likely benign - use CT to look for this

multiple myeloma can also be called what?

kahler’s disease

multiple myeloma

neoplastic proliferation of plasma cells primarily in the bone marrow - a monoclonal gammopathy that is tended to be seen more in people older than 50 and men slightly more than women - twice as common in African-Americans - 34% are asymptomatic at presentation

common findings in multiple myeloma

bone pain 58% (back, long bones, skull, ribs, pelvis), phytological fracture 26-34%, weight loss, fatigue, symptoms of hypercalcemia aka kidney problems (anorexia, nausea, vomiting, somnolence, polydipsia), recurrent infections (pneumonia), lytic bone lesions, bence jones protein, purpura - diffuse osteopenia - bone marrow reveals presence of at least 10% plasma cells - PEP shows M-spike

CRAB of multiple myeloma

elevated calcium, renal dysfunction/disease, anemia, bone lesions

multiple myeloma anemia

normocytic normochromic anemia, marked rouleax formation, serum globulins increased, elevated ESR

what types pf multiple myeloma do not show signs of CRAB

MGUS and smoldering MM

steps for if it looks like lytic metastasis

bone scan, MRI, biopsy

steps for if it looks like multiple myeloma

PEP of urine and blood, skeletal survey, MRI, biopsy

platelets (thrombocytes)

production is in bone marrow with differentiation of the stem cell - protect vascular integrity and initiate repair when vessels are damaged - normal is 150,000-400,000 - production is regulated by thrombopoietin

thrombocytopenia

decreased platelets due to failure to produce them or increased destruction - failure to produce may be found in disorders that affect marrow cell maturation such as aplastic anemia, leukemia, metastasis - due to destruction is from autoantibodies (idiopathic thrombocytopenia purpora - autoimmune thrombocytopenia) - drugs can also cause a reduction

thrombocytosis

elevated platelets usually due to secondary stimulation like post splenectomy or polycythemia vera - one out of two increases seen with malignancies somewhere in the body, mostly lung, GI, breast, ovarian, and lymphoma