Haematopathology
Haematopathology
Haematopathology
Blood Loss
Increased Red Cell Destruction
(Hemolytic Anemias)
Impaired Red Cell Production
A. Blood Loss
Acute Trauma, chronic lesions in GIT and gynecologic
disturbances
B. Increased Destruction (Hemolytic Anemias)
Intrinsic (intra corpuscular) abnormalities
Hereditary:
Membrane Skeletal Abnormalities Hereditary
Spherocytosis, elliptocytosis, membrane lipid
abnormality like abetalipoproteinemia
Enzyme deficiency: G6PD deficiency,pyruvate
kinase deficiency
Disorders of hemoglobin synthesis
deficient globin synthesis – Thalassemia
Structurally abnormal globin synthesis
sickle cell anemia, unstable hemoglobin
Acquired intracorpuscular abnormality
Membrane defect – Paroxysmal Nocturnal
hemoglublinuria
Extrinsic(extracorpuscular) abnormalities
antibody mediated e.g erythroblastosis
fetalis, Idiopathic auto immune hemolytic
anemia, transfusion reaction
Mechanical trauma to red cells. DIC, TTP,
infection like malaria
III Impaired Red cell Production:
Disturbance of proliferation and differentiation of stem cells.
Eg. Aplastic anemia, Pure red cell aplasia,anemia of
renal failure and endocrine disorders
Disturbance of proliferation and maturation of erythroblasts
Defective DNA synthesis: Vitamin B12 and folic acid
deficiency(megaloblastic anemia)
Defective hemoglobin synthesis
Deficient heme synthesis: iron deficiency
Deficient globin synthesis: thalassemia
Anemia of renal disorder
Unknown or multiple mechanism: myelodysplastic
syndrome, anemia of chronic inflammation,
myelophthisic anemia
Morphological Classification
Microcytic anemia (iron deficiency,
thalassemia)
Macrocytic anemia (folate, B12
deficiency)
Normocytic but with abnormal shapes
(hereditary spherocytosis, sickle cell
disease)
Clinical Manifestations
Acute: shortness of breath, organ
failure, shock
Chronic: pallor, fatigue and lassitude
With hemolysis: Jaundice, pigment gall
stones, skeletal abnormalities because
of expansion of marrow, growth
retardation; jaundice and gall stones
With defective erythropoiesis: iron
overload, heart and endocrine failure
Adult Reference Ranges for RBCS
Units Men Women
Lymphoblast Myeloblasts
Acute Lymphoblastic Leukemia
Acute Myeloid Leukemia
Immunological subtypes of ALL: Early pre B,
pre-B, mature B, immature T
About 80% of ALL are B cell origin.
Tdt is positive in 95% of cases
CD10 (CALLA) can be positive
Age less than 2, more than 10, male gender,
high WBC count, Ph chromosome and MLL
translocation carry bad prognosiss
Karyotypic change in ALL:
Non random karyotyping abnormalities
Most common is hyperdiploidy (> 50
chromosome per cell)
T(12;21) involving TEL1 and AML1 genes
– correlates with a good outcome
MLL gene translocation on chromosome
11q23 and ph chromosome – correlates
with poor prognosis
NOTCH1 activating mutation plays a
central role in the development of many
pre T ALLs
Prognosis in ALL
Good Prognosis: Children 2 to 10 years,
hyperdiploidy and t(12;21) have good
prgnosis
Worse outcome: Male gender, age
younger than 2 or older than 10 years,
high leucocyte count at the time of
diagnosis, rearrangement of MLL or the
Ph chromosome
Acute Myeloblastic Leukemia(AML)
Heterogeneous group, primarily affects older
adults, median age around 50 yrs.
Clinical signs symptoms closely resembles that
of ALL. ALL can present as discrete tissue mass
(granulocytic sarcoma)
Morphology of Myeloblasts: Nuclear chromatin
is delicate, finer with 3 to 5 nucleoli. Fine
azurophilic granules in cytoplasm. Auer rods
can be seen. Blasts are positive for peroxidase.
Lysosomal non specific esterase positive in
monoblasts. Tdt can be positive in 5% cases
Pathophysiology:
Most AMLs are associated with acquired
mutations in transcription factors that
inhibit normal myeloid differentiation
In AML-M3 (promyelocytic leukemia) –
fusion of retinoic acid receptor alpha
(RARA) gene on chromosome 17 fushes
with PML gene in chromosome 15;
chimeric protein inhit the function of
normal RARA receptors.
Pharmacological dose of retinoic acid, a
vitamin A analogue over come the block
Complementary mutation that enhances
proliferation (gain of function mutation in
FLT3) also play a role
AMLs are diverse in terms of genetics,
the predominant line of differentiation,
and the maturity of cells
Recurrent chromosomal abnormalities,
prior drug exposure and a history of a
myelodysplastic syndrome are predictive
of outcome
Acute Myeloid Leukemia
AML – M3 and AML – M5
Types of AML
M0 – Minimally differentiated AML
M1 – AML without maturation
M2 – AML with maturation
M3 – Acute promyelocytic leukemia
M4 – Acute mylomoncytic leukemia
M5 – Acute monocytic leukemia
M6 – Acute erythroleukemia
M7 – Acute megakaryocytic leukemia
By definition, in AML myeloblasts and
promyelocytes make up 20% of marrow
Auer rods are seen only in neoplastic
myeloblasts and thus a diagnostic clue
AML is a devastating disease.
T(8;21), inv(16), t(15;17) have favorable
prognosis
Prior drug exposure, MDS, multilineage
dysplasia, t(11q23) variant carry bad
prognosis
WHO classification of AML
Class Prognosis
DIC ?
TTP and HUS
TTP is associated with fever,
thrombocytopenia, microangiopathic
hemolytic anemia, transient neurologic
deficits and renal failure
HUS is also associated with
microangiopathic hemolytic anemia and
thrombocytopenia but there is absence of
neurologic symptoms, dominance of renal
failure and onset in child hood.
Overlap can occur
In both TTP and HUS there is
widespread formation of hyaline thrombi
in the microcirculation that are
composed primarily of dense
aggregates of platelet surrounded by
fibrin
Consumption of platelets results in
thrombocytopenia and platelet rich
thrombi results in microangiopathic
hemolytic anemia
Symptomatic TTP patients are deficient in
a metalloprotease called ADAMTS13 which
degrade very high molecular weight vWF
and hence in TTP, vWF accumulate which
cause platelet microaggregate formation
Lack of ADAMTS13 can be inheritd but it is
more commonly caused by acquired
antibody that inhibits it.
Early diagnosis should be suspected in
patients with thrombocytopenia and
microangiopathic hemolytic anemia,
otherwise it can be fatal
HUS occur in children after E.coli strain
O157:H7 which elaborates a shig like toxin
that damages endothelial cells and causes
platelet aggregation
Renal failure is frequent and plasma
exchanges are useful
Mutation in complement regulatory protein
factor H, leads to uncontrolled complement
activation after minor endothelial injury and
HUS
DIC is different from TTP and HUS
because coagulation cascade is activated in
DIC
Disseminated Intravascular Coagulation
(DIC)
An acute, subacute or chronic
thrombohemorragic disorder, DIC occurs
as a secondary complication in a variety of
diseases
Systemic activation of the coagulation
pathways, leading to the formation of
thrombi throughout the microscirulation
and there is consumption of platelets and
cogulation factors and secondarily
activation of fibrinolysis
Causes tissue hypoxia and microinfarcts
by myriad of microthrombi or to a
bleeding disorder related ti activation of
fibrinolysis and depletion of elements
required for hemostasis (consumptive
coagulopathy)
This entitiy is probably a more common
cause of bleeding that all the congenital
coagulation disorders combined
Two major mechanism can trigger DIC
Release of tissue factor or
thromboplastic substances into
circulation
Widespread endothelial cell damage
Thrombotic substances can be released in
circulation from placent in obstetric
complications, cytoplasmic granues in
PML or mucin secreting
adenocarcinoma, proteolytic enzymes
from tumour, endotoxin or exotoxin can
release tissue factor from monocytes.
IL1 and TNF increase the expression of
tissue factor on endotheial cells and
decrease the expression of
thrombomodulin
The net result is sthe enhanced actrivation
of extrinsic clotting system and blunting of
inhibitory pathways that tend to prevent
coagulation
Severe endothelial cell injury cause DIC by
release of tissue factor and by exposing
subendothelial collagen to vWF whichlead
to platelet aggregation and activation of
intrinsic cogulation cascade
Widespread endothelial injury can
produced by immune complex as in
SLE, temperature extremes, by
infections (particularly grand negative
sepsis)
DIC is most likely to occur after sepsis,
obstetric complications, malignancy and
major trauma (especially trauma to the
brain)
Shock, hypoxia and acidosis often
coexist and can lead to widespread
endothelial injury
The initating events in these conditions are
multiple and often inter related. Trauma to
brain releases fat and phopholipids which
can act as a contact factor and activate
intrinsic arm of coagulation cascade
DIC HAS TWO CONSEQUENCES
1. Widespread fibrin deposition within the
microcirculation. Leading to ischemia and
microangiopathic hemolytic anemia
2. Bleeding diathesis due to depletion of
platelets and coagulation factors and
fibrinolysis (formation of fibrin degradation
products
Major disorders Associated with DIC
Obstetric Complictions: Abruptio placentae,
retained dead fetus, septic abortion,
aminiotic fluid embolism, toxemia
Infections: sepsis, meniogococcemia, Rock
Mountain spotted fever, histoplasmosis,
Aspergillosis, Malaria
Neoplasms like carcinoma of pancreas,
prostate, lung, stomach, AML-M3
Massive tissue injury like major truma, burns,
extensive surgery
Miscellaneous: Snake bite, shock, liver disease
etc.
Morphology:
Microthrombi are found in arterioles and
capillaries of kidneys, adrenals, brain
and heart but no organ is spared
Bilateral renal cortical necrosis can
occur
Haemorrage and necrosis can occur in
adrenal (Waterhouse-Friderichsen
syndrome)
Micro infarcts in brain, heart and pituitry
(sheehan postpartum necrosis)
Larger than expected hemorraghes near
infarction but also diffuse petechiae and
echymoses in skin, serosa epi,
endocardium, lung and mucosa lining of
urinary tract
Clinical Course:
Acute DIC is dominated by a bleeding
diathesis whereas chronic DIC tends to
present with symptoms related to
thrombosis
Minimal manifestation to features of shock,
acute renal failure, dyspnea, cyanosis,
convulsions and coma
Laboratory evaluation reveals
thrombocytopenia and prolongation of PT
and PTT. Fibrin split products are
increased in the plasma
Prognosis is highly variable and depends
on the underlying disorder and severity
Acute cases are treated aggressively with
anticoagulants such as heparing or the
coagulants contained in fresh-frozen
plasma. Chronic cases sometime
identified as a laboratory abnormality.
Treatment should be directed at the cause
Coagulation Disorders
Due to either congenital or acquired
deficiencies of clotting factors
Most common are acquired coagulation
factor deficiencies, which typically affect
many factors simutaneously
Liver is the source of several
coagulation factors and parenchymal
diseases of liver are common causes of
complex hemorragic diatheses
Vitamin K is essential for synthesis of
prothrombin factors VII, IX and X and its
deficiency causes severe coagulation
defect
Hereditary deficiencies have been
identified for each coagulation factor.
Hemophilia A is due deficiency of factor
VIII and hemophilia B(Christmas
disease) is due to deficiency of factor IX-
both are X-linked recessive; other
deficiencies are autosomal disorder
Deficiencies of Factor VIII-vWF
Complex
Hemophila A and von Wilebrand disease, two of
the most common inherited disorders of
bleeding are caused by qualitative and
quantitative defects involving the factor VIII-vWF
complex
Plasma factor VIII-vWF complex is made up of
two protein. One is factor VIII, procoaguant
factor (deficiency of which cause hemophila A),
the other is a much larger proteinvWF whichis
found in plasma, platlets, endothelial cells and
in the subendothelium
The most important function of vWF is to
facilitate the adhesion of platelets to
damaged blood vessels
It bind to to platelets through the
receptors glycooprotein Ib and IIb/IIIa
Absence of vWF causes Von Wilebrand
disease
Several variants are known
Immunological technique and ristocetin
agglutination test serves as bioassay for
vWF
vWF is produced by endothelial cells
and megakaryocytes where as
procoagulant VIII is synthesized by liver
Synthesized separately, they come
together and circulate in the plasma as a
unit that serves to promote cloting as
well as the platelet-vessel wall
interactioon necessary to ensure
hemostasis
von Wilebrand Disease
Marked by spontaneous bleeding from
mucous membrane, excessive bleeding
from wound, menorrhagia and a prolonged
bleeding time in the presence of normal
platelet count
Most cases transmitted as autosomal
dominant disease
True incidence not well known, perhaps the
most common inherited bleeding disorder
The classic and most common variant of
von Wilebrand disease (type1) is an
autosomal dominant disorder characterized
by a reduced quantitity of circulating vWF
Secondary decrease in procoagulant factor
VII to levels that are clinically significant
The other less common variant there is
both qualitative and quantiative defects in
vWF. Type II is divided into several types
with selective loss of high molecular weight
multimers of vWF
In type IIA, high molecular weight is not
not synthesized but in type IIB it is
synthezised but rapidly cleared.
Remember in TTP there is accumulation
of very high mollecular weight multimer
of vWF because of absence of
ADAMTS13
Factor VIII Deficiency (Hemophilia A,
Classic Hemophilia)
Hemophilia A is the most common
hereditary disease associated with
serious bleeding.
It is an X-linked recessive disorder that
is caused by reduction in factor VIII
activity
Primarily affects males. Can affect
females in case of extremly
unfavourable Lyonization
30% of cases due to fresh mutation and in
the reminder there is positve family history
Severe hemophilia occurs when the
concentration of factor VIII is below 1%
Milder deficiencies may become apparent
when major hemodynamic stress such as
truma supervene
As in thalassemia several type of genetic
lesion such as deletion, splice junction
mutations, nonsense mutation have been
identified. Explains the various degree of
VIII deficiency
In 10% of cases immuno assay of factor
VIII is normal but bioassay is low –
synthesis of functionally abnormal
protein
Clinically easy brusing and massive
hemorrage after trauma or operative
procedures. Hemoarthroses lead to
crippling deformity. Petechiae are
characterstically absent.
Prolonged PTT that is corrected by
mixing the patient’s plasma with normal
plasma
In 15% cases replacement therapy is
complicated by the development of
neutralizing antibody and in these cases
PTT fails to correct in mixing studies.
Specific factor VII assay is required to
confirm the diagnosi of hemphilia A
Treatment involves infusion of factor
VIII.
The availability of widespread use of
recombinant factor VII and more highly
purifed factor VIII concnetrates now
eliminated the risk of AIDS
Factor IX Deficiency (Hemophilia B,
Christmas Disease)
X linked disorder that is
indistinguishable clinically from
hemophilia but is much less common
PTT is prlonged bu the bleeding time is
normal
Diagnosis is made with specific assays
of factor IX
Treated by infusion of recombinant
factor IX
Summary of Bleeding Disorders
Disseminated Intravascular Coagulation:
syndromes in which systemic activation of
the coagulation system by various stimuli,
like sepsis, massive tissue injury, release of
procagulatnt factors from tumor cells ,
obstetric complication leading to
consumption of coagulation factors and
platelets
Clinical pictures is due bleeding, vascular
occlusion and tissue hypoxemia.
Immune thrombocytopenic Purpura (ITP):
is caused by autoantibodies to platelet
antigens may be trigered by drugs, infections
or lymphomas or be idiopathic
Thrombotic Thrombocytopenic purpura
(TTP):Acquired or inherited deficiencies of
ADAMTS13, a plasma metalloprotease that
prevents the accumulation of high multipers
of vWF. Leads to platelet rich thrombi in
kidney and CNS
Hemolytic Uremic Syndrome: Resembles TTP
clinically, but cause deficiency of complement
regulatory protein factorH, or Shiga like toxin
elaboratged by certain strain of E.coli.
Endothelial injury causes platelet aggregation
and microvasculature thrombosis
Von Wilebrand Disease: Autosomal disorder
caused by mutation of vWF, which normally
function as a bridging molecule between
platelets and sub endothelial collagen.
Causes a mild to moderate bleeding disorder.
Hemophilia A: It is an X linked disorder
caused by mutation in coagulation factor VIII.
Affected males typically present with severe
bleeding into soft tissue and joints and have
prolonged partial thromboplastin time (PTT)
Hemophilia B is an X-linked disorder
caused by mutation in coagulation factor IX;
clinically, it is identical to hemophilia A.
Disorders That Affect The Spleen And
Thymus
Spleen is frequently secondarily
involved in a wide variety of systemic
disease
Evaluation of splenomegaly is a
common clinical problem that is aided
considerably by knowledge of the usual
limits of spelenic enlargement that is
seen in the context of specific disorders
A. Massive Splenomegaly (Weight more
than 1000 gm)
Chronic Myeloid Leukemia
Myelofibrosis with myeloid metaplasia
Hairy cell leukemia
Chronic malaria
Gaucher disease
Lymphomas
Chronic lymphocytic leukemia
Primary tumours of the spleen (rare)
B. Moderate Splenomegaly (weight 500-
1000 gm)
Chronic congestive splenomegaly (portal
hypertension or spenic vein obstruction)
Acute leukemia (inconstant)
Hereditary spherocytosis
Thalassemia major
Autoimmune hemolytic anemia
Niemann-Pick disease
Langerhans histiocytos
Chronic splenitis ( as in infective endocarditis
Tuberculosis, sarcoidosis, typhoid
C. Mild splenomegaly(weight <500 gm)
Acute spenitis
Acute splenic congestion
Infectious mononucleosis
Miscellaenous acute febrile disorders
including septicemia, SLE and intra-
abdominal infections
Hypersplenism refers to enlarged spleen
which removes excessive numbers of one
or more of the formed elements of blood,
resulting anemia, thrombocytopenia and
leuckopenia
Platelets are particularly susceptible to
sequestration and as a result
thrombocytopenia is more prevalent and
sever in individuals with splenomegaly
than are anemia or neutropenia
Disorders of the Thymus
Thymus is a welll known central
lymphoid organ that has a crucial role in
T-cell differentiation
Thymus is involved in T cell lymphoma
particularly T lymphoblastic lymphoma
The two most frequent disorders of the
thymus are thymic hyperplasia and
thymoma
Thymic Hyperplasia
Hyperplasia is often associated with
lymphoid follicles with germinal centres
within the medulla
Thymic follicular hyperplasia is present
in most patients with myasthenia gravis,
some times in SLE, RA.
Removal of the hyperplastic thymus is
often beneficial early in the disease
Thymoma
Thymoma by definition, is a tumour of
thymic epithelium. Lymphoid cells seen are
non neoplastic
Several type of classification of thymoma
are known
One simple classification is Benign
Thymoma, Malignant Thymoma – Type I:
cytologically benign but invasion is present.
Type II – thymic carcinoma. Cytologically
malignant
Morphology:
Gross: Lobulated, firm, gray white masses up to
15 to 20 cm. Most appears encapsulated, but
in 20 to 25% cases capsular infiltration into
perithymic tissue are seen
Micro: Mixture of epithelial cells and variable
infiltrate of non neoplastic lymphoid cells. Type
A Thymomas (medullary thymoma) are spindle
shaped. Type B thymomas (cortical thymomas)
have plumper, polyhedral thymic epithelial cells
with variable mixture of lymphoid cells (B1 to
B3). Thymoma C are atypical thymomas
Acute intersecting fibrous bands, presence of
serum lakes, palisading around blood vessels,
some time corticomedullary differentiation help
for the diagnosis
CD1a and Tdt will be positive in cortical
thymocytes. Thymoma cells will be positive for
pan CK. In Thymic carcinoma CD5 may be
positive
Malignant thymoma type I: It is cytologically
bland but locally invasive. The critical
distinguishing feature is the penetration of the
capsule and the invasion of surrounding
structures
Malignant type II is Thymic carcinoma.
Represent about 5% of thymoma. In contrast
to type I, cytologically malignant and grossly,
they are fleshy, obviously invasive masses
some times accompanied by metastases to
such sites as lungs. Many types are known
like squamous cell carcinoma,
lymphoepithelioma-like carcinoma (EBV
related) and other types
Clinical features of Thymoma:
All are rarities, the malignant more so than the begin
They may arise at any age but typically occur in
middle adult life
30% asymptomatic; 30 to 40% produce local
manifestations such as mass demonstrated in
CT/MRI, associated with cough, dyspnea and
superior vena caval syndrome
Reminder associated with some systemic disease
principally myasthenia gravis,
hypogammagloblinemia, pure red cell aplasia, SLE
and non thymic cancer
Removal of thymoma leads to improvement in
myasthenia gravis