HEMATOPATHOLOGY

 Disorders of the haematopoietic and

lymphoid system encompass a wide
range of diseases
 Pathogenic derangements primarily
affecting one cell type often lead to
alteration in others
 Other levels of interplay and complexity
can occur
Definition of Anemia
 Anemia is a reduction in the oxygen
transporting capacity of blood, which
stems from a reduction of the total
circulating mass to below normal
amount
 Decreased Hemoglobin. Below 13
gm/100 ml in men and below 12gm/100
in women, 11 gm/100 ml in pregnant
woman and children
Classification of Anemia According to
Underlying Mechanism

 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

Hb g/dL 13.6 to 17.2 12 -15

Hematocrit % 39-49 33-43

RBC count 106 / cmm 4.3 to 5.9 3.5 to 5

Reticulocyte % 0.5 to 1.5 0.5 to 1.5

count

MCV fL 76-100 76-100

MCH pg 27-33 27-33

MCHC g/dL 33-37 33-37

RDW 11.5 to 14.5 11.5 to 14.5

Anemia of Blood Loss
 Acute blood loss: hypovolemic shock.
Later hemodilution occurs and
normocytic, normochromic anemia.
Reticulocytosis occur
 Chronic blood loss. Iron stores are
depleted and leads to iron deficiency
anemia
Hemolytic anemia
 Marked erythroid hyperplasia within the
marrow and increased reticulocyte count in
peripheral blood
 Extra medullary hematopoiesis can occur
in spleen, liver and lymph node
 Intravascular hemolysis: leads to
hemoglobinemia, hemoglobinuria and
hemosiderinuria. Jaundice due to
unconjugated hyperbilirubinemia.
Haptoglobin is decreased. Can lead to ATN
of kidney
 Extravascular hemolysis: No
hemoglibinemia or hemoglobinuria,
Jaundice and bilirubin rich gall stones
occur. Haptoglobin is decreased.
Reactive hyperplasis of mononuclear
phagocyte system which results in
splenomegaly
 In hemolytic anemia, changes in iron
metabolism, increased iron absorption
from GIT, hemosiderosis and in severe
cases secondary hemochromatosis
occur
Erythroid Hyperplasia in bone marrow
Hereditary Spherocytosis
 Autosomal dominant disorder caused by
inheritted mutation that affect RBC
membrane skeleton(involve spectrin, ankyrin
and band 3). Some time autosomal recessive
inheritance
 Leads to loss of membrane and eventual
conversion of RBCs to spherocytes which
are phagocytosed and removed in the spleen
 Manifested by anemia, splenomegaly and
jaundice
 Intrinsic defect of RBC membrane that
renders the cells lessdeformable and
vulnerable to splenic sequestration and
destruction
 Vertical spectrin-intrinsic membrane
protein interaction is weakened.
 The critical role of the spleen is
illustrated by the invariably beneficial
effect of splenectomy; although RBC
defect and spherocytes persist, the
anemia is corrected
Hereditary Spherocytosis
 Red cells show increased osmotic
fragility when placed in hypotonic salt
solutions
 Aplastic crisis can occur triggered by
parvovirus B19
 Splenectomy is beneficial
Peripheral Smear in Hereditary
Spherocytosis
Hemoglobinopathies
 Hemoglobinopathies are a group of
hereditary disorders defined by the
presence of structurally abnormal
hemoglobins. More than 300 variant
hemoglobin have been discovered
 Sickle cell anemia is a prototype of
qualitative hemoglobinopathy
 Sicle cell anemia is the most common
form of familial hemolytic anemia
Sickle Cell Anemia
 Autosomal recessive disorder that results from a
mutation in beta globin
 Substitution of valine for glutamic acid at the sixth
position of beta chain produces HbS.
 Deoxygenation causes HbS to self associate into
long polymers that distort(sickle) RBCs
 Common in blacks 8 to 30% . Protects against
falciparum malaria – balanced dimorphism
 The degree of sickling depends on the presence
of hemoglobin other than HbS, concentration of
HbS and the degree of low oxygen tension
 The length of time that red cells are
exposed to low oxygen tension is
important. Spleen and marrow blood
flow is sluggish. Inflammation and
increased endothelial stickling adds up
to the problem
 Two major consequences stem from the
sickling of red cells. Chronic
extravascular hemolysis and widespread
microvascular obstruction resulting in
ischemia and pain crises
Sickle Cell Anemia
 Blockage of vessels by aggregates of sickled
cells causes acute pain crises and tissue
infarction-vaso occlusive or pain crises
 Red cell membrane damage that attends
repeated bouts of sickling results in a moderate to
severe hemolytic anemia
 In children splenomegaly but chronic
erythrostasis results progressive hypoxic
damage. Autosplenectomy is complete by
adulthood
 Prone for pneumococal penumonia and
Salmonella osteomyelitis
 Aplastic crisis can occur
 Peripheral smear shows, bizarre elongated,
spindled or boat shaped irreversibly sickled
red cells
 Vascular congestion,thrombosis and infarction
can affect any organ including bones, liver,
kidney, retina, brain, lung and skin
 Acute chest syndrome and stroke are the two
leading causes of ischemia related death
 Priapism and eventual erectile dysfunction
 Hemosiderosis and gall stone are common
 Hemoglobin electrophoresis is helpful in
diagnosis
 Prenatal diagnosis is possible
Peripheral Blood Smear in Sickle Cell
Anemia
Thalassemia
 Heterogenous group of autosomal co-dominant
disorders in which mutation in the alpha or beta
globin genes result in reduced hemoglobin
synthesis. Additional secondary red cell abnormality
is caused by excess of unaffected globin chain
 Results in microcytic, hypochromic anemia
 In beta thalassemia, unpaired alpha globin chains
form aggregates that damage RBC precurors and
further impair erthropoiesis
 Beta thalassemia is common among Mediterranean
population
 Adult HbA, is a tetramer composed of
two alpha chains and two beta chains.
The alpha chain is encoded by two
globin genee which lie in tanderm on
chromsome 11, while the beta chain is
encoded by a single beta globin gene
located on chromosome 16.
Beta Thalassemia
 Beta globin mutation associated with B
thalassemia fall into two categories
 Bo in which no beta globin chains are
produced

 in which there is reduced but

B+

detectable beta globin synthesis

 Hundred different type of mutation can
result in beta thalassemia
 Thalassemia major is a homozygous state –
disease is severe and requires blood
transfusions regularly
 Thalassemia trait is a heterozygous state,
asymptomatic with or without anemia
 Beta thalassemia is due to transcription,
translation or RNA splicing defect in beta
globin gene
 Alpha thalassemia is due to gene deletion
 Skeletal deformity, hepato splenomegaly occur
 Secondary hemosiderosis, growth retardation
and cachexia occur in thalassemia major
 Unlike alpha thalassemia gene deletions
rarely underline beta thalassemia
 Persons inheriting any two beta 0 or
beta + alleles have beta thalassemia
major
 Individual inheriting two beta + alleles
have a milder disease termed beta
thalassemia intermedia
Beta Thalassemia – Gene Defect
Common mutations in Beta thalassemia

 Mutation in promoter region(transcription

defect) leads to reduced globin gene
transcription. Beta +
 Mutation in the coding sequence. Single
nucleotide change in exon (translation
defect) can lead to stop codon and
completely prevents the synthesis of
beta chain. Beta 0
 Mutation that lead to aberrant mRNA
processing are the most common
cause of beta thalassemia. Most of
them occur at introns but some have
been located within exons.If the
mutation alter the normal splice junction,
splicing does not occur and all mRNA
formed is abnormal. Mutation can occur
sites away from normal intron-exon
splice junction. Both normal splicing and
abnormal splicing can occur leading to
Beta 0 or beta + alleles
Two condition contribute to the pathogenesis
of the anemia in beta thalassemia
1. Reduced synthesis of beta globin leads
to inadequate HbA formation – Microcytic
hypochromic anemia with reduced MCHC
2. Red cell hemolysis due to unbalanced
rate of beta and alpha chain. Excess
alpha chain form insoluble aggregates,
precipitates and cause membrane
damage provoking extra vascular
hemolysis
 Erythroblasts in bone marrow is also
affected with excess alpha chain
resulting in destruction and ineffective
erythropoiesis resulting in jaundice,
increased absorption of dietary iron and
increased iron over load.
Alpha Thalassemia
 The molecular basis of alpha thalassemia
is quite different from that of beta
thalassemia
 Most of alpha thalassemia is due to
deletion of alpha globin gene from
chromosome 11
 Loss of single gene – silent carrier, loss of
all four gene – Hydrops foetalis, loss of
three genes – HbH and HbBart. Loss of
two gene – alpha thalassemia trait
 HbH and Hb Bart have abnormally high
affinity for oxygen which renders them
ineffective at delivering oxygen to the
tissue
 Less membrane damage by HbH, Hb
Bart, therefore hemolytic anemia and
ineffective erythropoies is less in alpha
thalassemia
 Iron overload is rarely seen
Morphology:
 Beta thalassemia minor, the abnormalites
are confined to peripheral blood. Microcytic,
hypochromic anemia, targets cells are often
seen, marked poikiocytosis, anisocytosis,
reticulocytosis, nucleated red cells are seen

 Anatomic changes in beta thalassemia are

similar to other hemolytic anemia but
extreme in degree. Marked hyperplasia of
bone morrow further leading to skeletal
deformity
 Extramedullary hematopoiesis can
occur. Prominent splenomegaly,
hepatomegaly and lymphadenopathy
can occur. Ineffective erythropoietic
precursors consume nutrient and
produce growth retardation and result in
cachexia.
 Iron overload and severe hemosiderosis
develop
Clinical Features:
In Beta thalassemia major:
Affected children fail to develop normally,
growth is retarded, need repeated blood
transfusion. Later systemic iron over
load develops. Low levels of hepcidin
leads to increased iron absorption.
Cardiac failure, secondary
hemochromatosis lead to death in
second or third decade . Diagnosis is
made on clinical ground, peripheral
smear, Hb electrophoresis
In beta thalassemia minor:
Mild microcytic hypochromic anemia.
Patients have normal life expectancy.
Peripheral smear mimicks iron
deficiency anemia. Diagnosis is made
by Hb electrophoreis. Reduced HbA,
level of HbA2 is increased.
Prenatal diagnosis of thalassemia can be
made by DNA analysis
Glucose-6-Phosphate Dehydrogenase
Deficiency
 RBCs are vulnerable to injury by
endogenous and exogenous oxidation
which are normally inactivated by
reduced glutathione (GSH)
 Abnormalities affecting the enzymes that
are required for GSH production leads to
oxidative injury and hemolytic anemias
 G6PD deficiency is a prototype and
G6PD variant is carried in 10% blacks
 400 variants are known and G6PD A- variant
has normal enzymatic activity but a
decreased half life
 X linked recessive disorder
 Older RBCs are more affected
 Precipitated by infection and
drugs(antimalarials, sulfonamides,
nitrofurantoin, phenacetin, aspirin and
vitamin K derivatives) which cause oxidation
stress
 H2O2 generated attack various component
including Hb and precipitate Heinz bodies
which can damage cell membrane and
induce intravascular hemolysis, splenic
macrophages further damage the cells
 G6PD Mediterranean found mainly in middle
east cause more severe hemolysis
 Heterogenous females have two distinct cell
population
Paroxysmal Nocturnal Hemoglobinuria (PNH)

 Acquired membrane defect secondary to a

mutation that affects myeloid stem cells.
 The mutant gene PIGA is required for the
synthesis of a specific type of
intramembranous glcolipid anchor,
phophatidylinositol glycan (PIG)
 Without the membrane anchor PIG certain
protein cannot be expressed on the surface
like protein which can limit spontaneous
activation of complement
 As a result the RBCs are inordinately
sensitive to the lytic activity of complement
 It is believed hemolysis is nocturnal because
the blood becomes acidic during sleep (C02
retention)
 Several PIG-tailed proteins are deficient in
granulocytes and platelets explaining
susceptibility to infection and intravascular
thrombosis
 PIGA is X-linked and the responsible
mutation occur in a multipotent stem cells
 Rare disorder
 Clinically evident PNH occurs only in rare
instances in which the PIG deficient clone
has survival advantage, one is the setting of
primary bone marrow failure (aplastic
anemia)
 Therapy with antibody that inhibits the C5-9
complement membrane complex (and
thereby red cell hemolysis) is currently under
evaluation
Immunohemolytic Anemias
 Antibodies that recognize determinants
on RBC membranes causes these
uncommon forms of hemolytic anemia
 Can occur spontaneously or by
exogenous agents such as drugs and
chemicals
 Classified based on 1. the nature of the
antibody and 2. the presence of certain
predisposing condition
Classification of Immunohemolytic
Anemias
Warm Antibody Type
Primary (idiopathic)
Secondary: B cell lymphoid neoplasma
(eg.CLL), autoimmune disorders (eg.SLE),
drugs (eg. Alpha methyldopa, penicillin,
quinine)
Cold Antibody Type
Acute: Mycoplasma infection, infectious
mononucleosis
Chronic: Idiopathic, B cell lymphoid neoplasm
 Diagnosis of immunohemolytic anemia
dependes on detection of antibodies and/or
complement on patient RBCs by Direct
Coombs antiglobuin test
 Indirect Coombs Test: Patient serum is
tested for the ability to agglutinate defined
red cells
Warm Antibody Immunohemolytic
Anemias
 Caused by IgG and rarely by IgA which are active at
37 degreeC
 Most cases are idiopathic(primary) 60%, others are
due to SLE or drugs
 The hemolysis usually results from the opsonization of
red cells by the autoantibodies which leads to
erythrophagocytosis in the spleen
 Spherocytes are formed (reduced surface area to
volume)
 Most patients have chronic mild anemia with
moderate splenomegaly and often requires no
treatment
 Mechanisms induced by drugs are varied.
Alpha methyl Dopa induce autoantibodies
directed against Rh group of antigens.Drugs
alter native epitopes and allows by pass of T
cell tolerance.
 Pencillin act as haptens and induce an
antibody response by binding to a red cell
membrane protein. Some time immune
complexes are deposited on red cells and
may fix complement or act as opsonins
Cold Antibody Immunohemolytic
Anemias
 Caused by low affinity IgM antibodies which
binds to red cells only at low temperature below
30 degree C which are commonly experienced
in in distal parts like hands, toes and ears. At
low temperature IgM fix complment and at warm
temperature it is dissociated, C3b act as
opsonin and hemolysis is extravascular
 Inaddition to anemia, Raynaud phenomenon
often occurs in these patients as result of
agglutination of red cells in capillaries of
exposed parts of the body
Hemolytic Anemias Resulting from
Mechanical Trauma to Red Cells
 Traumatic hemoytic anemias can be seen in
marathon racing and bongo drumming as well
by cardiac valve prostheses
 Microangiopathic hemolytic anemia is
observed when small vessels become partially
obstructed. DIC, malignant hypertension, SLE,
TTP, HUS, disseminated cancer. Peripheral
smear shows burr cells, helmet cells and
triangle cells – offer diagnostic clue, hemolysis
is not a major clinical problem
Malaria
 Most wide spread afflictions of humans
 Endemic in Africa and Asia
 Plasmoidum falciparum causes
malignant tertian malaria with high
fatality
 P.vivax, P.ovale and P.malariae cause
relatively benign disease
 Transmitted by female Anopheles
mosquitoes
 Showers of merozoites are released from red
cells at intervals of 48 hours in
P.vivax,P.ovale and P.falicparum and 72
hours in P.Malariae. Spikes of shaking chills
and fever coincide with this release
 The parasites destroy large number of red
cells and thus cause hemolytic anemia
 A characteristic brown malarial pigment
identical to hematin is relased from red cells
and deposited in liver, spleen, lymphnode
and bone marrow
 Activation of the phagocytic defense
mechanism of the host leads to marked
hyperplasia of mononuclear phagocyte system
reflected by massive splenomegaly
 Fatal falciparum malaria causes cerebral
malaria and another dramatic complication is
black water fever with massive hemolysis,
jaundice, hemoglobinemia and hemoglobinuria
 Early diagnosis and treatment are particularly
important.
 Drug resistant and lack of effective vaccine are
problem areas
Anemias of Diminished Erythropoiesis
 Include anemias that are caused by an
inadequate dietary supply like iron, folic
acid and vitamin B12
 Disorders that suppress erythropoiesis
include bone marrow failure (aplastic
anemia), replacement of bone marrow
by tumor or inflammatory cells
(myelopthisic anemia)
Iron Deficiency Anemia
 Iron deficiency is the most common form of
nutritional deficiency and results in anemia –
10% of population affected in developed
countries, 25 to 50% in developing countries
 Low dietary intake (only in poorer countries),
malabsorption (celiac disease, spure, after
gastrectomy), increased demand as in pregnancy
and infancy and chronic blood loss from GIT
(hook worm disease, colonic cancer, peptic ulcer
etc) or from female genital tract (menorrhagia,
cancer) are the causes of iron deficiency anemia
 Total body iron content is about 2 gm for
woman and 6 gm in men.
 80% functional body iron is found in Hb,
remainder in myoglobin, iron containing
enzymes like catalase and cytochromes.
 Iron storage pool, represented by
hemosiderin and ferritin bound iron – 15 to
20% of total body iron mainly found in liver,
spleen, bone marrow and skeletal muscle
 Serum ferritin level, plasma transferin level
and assessment of bone marrow iron are
methods of estimating body iron content
 Iron balance is largely regulated by the
absnorption of dietary iron
 Only 1 to 2 mg of iron is lost everyday
 Normal, good diet contains 10 to 20 mg
of iron
 Heme iron is better absorbed than
nonheme iron in duodenum
 Non heme iron is first reduced to ferrous
state by ferric reductase. Divalent metal
transporter (DMT1) transports it across
apical membrane.
 Ferroportin and hephaestin are
required for the basolateral transfer of
iron to transferin in the plasma
 Only a fraction of the iron that enters the
cell is delivered to plasma tranferrin by
the action of ferroportin, the remainder is
bound to ferritin and lost through the
exfoliation of mucosal cells
 When body is replete with iron, most of
the iron that enters duodenal cells is
bound to ferritin and never transferred to
transferrin; in iron deficiency and
And in ineffective hematopoiesis, transfer
to plasma transferrin in enhanced. This
balance is regulated by hepcidin
 When hepcidin concentrations are high,
ferroportin levels fall and less iron is
transferred out of enterocytes to
transferrin
 Conversely, when hepcidin levels are
low as in hemochromatosis, transport of
iron from the enterocytes to plasma is
increased resulting in systemic iron over
load
 Iron deficiency develops insidiously
 First decline in serum ferritin and
absence of stainable iron in the bone
marrow
 Decrease in serum iron and rise in
serum iron-binding capacity
 Later decreased Hb
 Impaired work and cognitive
performance and even reduced
immunocompetence
 Clinical Features: In most instances, iron
deficiency anemia is asymptomatic. Non
specific manifestations such as
weakness, listlessness and pallor, long
standing cases spooning of finger nails
some time, some time neurobehaviourl
complication like pica.
 Iron deficiency results in microcytic,
hypochromic anemia. MCV and MCH are
decreased. Thrombocytosis can occur. Marrow
cellularity is slightly increased with normoblstic
erythropoiesis, micronormoblasts and persistent
basophilia in late normoblasts.
 Low serum ferritin, low serum iron level, low
transferin saturation, increased total iron binding
capacity
 In a reasonably well nourished persons,
microcytic hypochromic anemia is not a disease
but rather a symptom of some underlying
disorder
Iron deficiency anemia. Microcytic
Hypochromic anemia
Anemia of Chronic Disease
 Most common form of anemia in
hospitalized patients
 Superfically resembles anemia of iron
deficiency
 Occurs in a variety of chronic inflammatory
disorders like osteomyelitis, bacterial
endocarditis, lung abscess; chronic immune
disorders like RA, Crohn’s and neoplasms
such Hodgkin lymphoma, carcinoma of lung
and breast
 Can result in microcytic hypochromic anemia
as well as normocytic normochromic anemia
 Although serum iron level is low, there is
increased storage iron in the bone
marrow, high serum ferritin concentration
and reduced total iron binding cpacity all
of which readily rule out iron deficiency
 High concentration of hepcidin which inhibits
ferrooportin and there by block the transfer o
firon from storage pool to functional pool
 Chronic inflammation also blunts the
compensatory increase in erythropoietin level
Megaloblastic Anemias
 Two principal causes are vitamin B12
deficiency and folate deficiency
 Both are required for DNA synthesis and so
effect are similar(delay in nuclear maturity)
 Megaloblasts are abnormally large red cell
precursor giving to macrocytes (large RBCs)
 Giant metmylocytes and hypersegmented
neutrophils are seen
 Megakaryocytes too, may be abnormally
large and have bizarre multilobed nuclei
Megaloblasts
Macroovalocytes
Hypersegmented Neutrophil
 Cellular giantism is due to impairment of DNA
synthesis which results in a delay in nuclear
maturation and cell division. Cytoplasmic
maturation outpaces that of nucelus
 Hematopoietic precursors show nuclear
cytoplasmic asynchrony.
 Megaloblasts undergo apoptosis and hence
Ineffective hematopoies occurs.
 Granulocytes and platelet precursors are
similarly affected and result in pancytopenia
(anemia, thrombocytoopenia and
granuocytopenia)
 Bone marrow is markedly hypercellular.
Increased megaloblasts.
 Peripheral smear show large, egg-
shapedmacro ovalocytes,
hypersegmented polyps. MCV is often
greater than 110fL(normal 82-92fL).
MCHC is normal. Large mishapen
platelet may also be seen. Other
systems like GIT mucosa can also be
affected
Folate(Folic Acid) Deficiency Anemia
 Megaloblastic anemia secondary to
folate deficency is not common in
western world but marginal folate stores
occur even in health individuals
 Causes of Folic acid deficiency:
Decrease folate in diet, Increased
demand as in pregnancy, malabsorption
(as in celiac disease and sprue), drugs
like methotexate, phenytoin
 Best source of folate are fresh uncooked
vegetables and fruits
 Tetrahydrofolate acts as an acceptor
and donor of one carbon units in the
synthesis of purine and thymidylate, the
building block of DNA. Hence folic acid
deficiency leads to inadequate DNA
synthesis and megaloblastic anemia
 No neurological symptoms(sub acute
degeneration of spinal cord) in folate
deficiency, where as it occurs in B12
deficiency
 The anemia of folate deficiency is best
distinguished from that of vitamin B12
deficiency by measuring serum and red
cell folate and vitamin B12 levels
Vitamin B12(Cobalamin) Deficiency
anemia: Pernicious Anemia

 Causes of B12 deficiency: Decreased

dietary intake(very rare), autoimmune
gastritis (pernicious anemia with
resulting antibody against intrinsic factor
to vitamin B12, gastrectomy, diseases of
distal ileum (Crohn’s disease, tropical
sprue, Whipple disease), surgical
resection of ileum
 Peptic digestion releases dietary vitamin B12,
which then binds to salivary B12 binding
protein called coabalphilins or R binders
 R-B12 complexes are transported to the
duodenum and processes by pancreatic
proteases, this releases B12; which attaches
to intrinsic factor secreted from parietal cells
of the gastric fundic mucosa
 The intrinsic factor-B12 complexes passes to
the distal ileum and attaches to epithelial
intrinsic factor receptor which leads to
absorption of vitamin B12
 The absorbed B12 is bound to transport
protein called transcobalamins, which
then deliver it to the liver and other cells
of the body
 Among the many potential causes of
cobalmin deficiency, long-standing
malabsorption is the most common and
important
 Deficiencies due to diet are virtually
confined to strict vegans
 Liver store is enough for 5 to 20 years
 Until proved otherwise, a deficiency of
vitamin B12 (in western world) is caused
by pernicious anemia – an autoimmune
reaction against parietal cells and
intrinsic factor itself, which produce
gastric mucosal atrophy
 Parietal canlicular antibodies, blocking
antibodies, binding antibodies are
known
 Pernicious anemia is associated with
other autoimmune diseases
 Vitamin 12 is required for recycling of
tetrahydrofolate and hence B12
deficiency reduces the availability of the
form of folate required for DNA synthesis.
 As expected, given this relationship, the
anemia of vitamin B12 deficiency
improves with administration of folates.
 In contrast, the biochemical basis of
neuropathy in vitamin B12 deficiency is
unclear, administration of folate may
actually exacerbate the neurological
disease
 The prinicipal neurological lesions is
demyelination of posterior and lateral columns
of spinal cord. The severeity of neurological
manifestations is not related to the degree of
anemia, some time neurological disease
occurs in the absence of overt megaloblastic
anemia
 Clinical manifestations may be non specific.
Mild jaundice can occur. Numbess, tingling
and burning in feet and hands followed by
unsteadiness of gait and loss of position
sense particular in toes.
 Increased risk of gastric carcinoma in
perinicious anemia
 Diagnostic features of pernicious
anemia include
Low serum vitamin B12 level
Normal or elevated serum folate levels
Serum antibodies to intrinsic factor
Moderate to severe megaloblastic anemia
Leukopenia and hypersegmented
granulocytes
A dramatic reticulocyte response (within 2-
3 days) to paternal administration of
vitamin B12
Aplastic Anemia
 Aplastic anemia is a disorder in which
multipotent myeloid stem cells are
suppresssed, leading to marrow failure and
pancytopenia
 More than half of cases aplastic anemia is
idiopathic, in the reminder exposure to
myelotoxic agents such as drugs and chemicls
 Damage to predictable, dose related agents
are reversible. Includes antineoplastic drugs,
benzene and chloramphenicol
 Due to apparent idiosyncratic or hypersensitive
reaction to a small dose of known myelotoxic
drugs (eg.chloramphenicol) or drugs such as
sulfonamides which are myelotoxic in other
persons
 Can occur after viral infections such viral hepatitis.
The specific virus resposible is not known. Marrow
aplasia develops insidiously several months after
recovery from hepatitis and follows a relentless
course. Autoreactive T cells may play a role.
Responds to immunosuppressive therapy aimed
at T cells. Probably neo antigen within stem cells
due to viraus, drugs or genetic damage
 Small fraction of patients with acquired
aplastic anemia have inherited defects in
telomerase. In these setting intrinsic defects
lead directly to damage and senescence of
hematopoietic stem cells
 Morphology: Bone marrow is marked
hypocelluar. Fat occupies 90% of the
intertrabecular space. Only lymphocytes an
plasma cells are seen. Aspiration is usually a
dry tap.Fatty change in liver, hemorrhage
and bacterial infection can be seen
 Clinical Course: Aplastic anemia affects persons
of all ages and both sexes. Anemia causes
weakness, pallor and dyspnea.
Thrombocytopenia often presents with petechiae
and ecchyoses. Granulocytpenia may result
persistance of infection, fever, chills and
prostration.
 Pancytopenia can be caused by other causes
like aleukemic leukemia, myelophthisic anemia,
so bone marrow examination is a must
 Spenomegaly is characterstically absent in
aplastic anemia, if it is present the diagnosis
should be seriously questioned
 Pancytopenic peripheral smear. Normocytic
normochromic anemia. Reticulocytopenia.
 Prognosis of marrow aplasia is quite
unpredictabe. Idiopathic form has a poor
prognosis if left untreated. Bone marrow
transplantation is an extremely effective form
of therapy especially if performed in
nontrasnsfused patients, younger than 40
years. Transfusion sensitize patients to
alloantigens, producing a high engraftment
failure
Myelophthisic Anemia
 This form of anemia is caused by the
extensive replacement of the marrow by
tumours or other lesions. Caused by
metastatic breast, lung and prostatic cancer,
tuberculosis, lipid storage disorder,
osteosclerosis. Marrow infiltration include
anemia and thrombocytopenia. WBCs are less
affected. Tear drop cells and immature
granulocytic and erythrocytic precursors are
seen with slightly elevated WBC count.
Leukoerythroplastic picture.
Laboratory Diagnosis of Anemias
 Diagnosis of anemia is establised by
decrease in the hemoglobin and
hematocrit levels below normal
 Peripheral Smear examination offers
important clue
 Following specialized tests are
particularly important in establishing the
diagnosis of certain types of anemia
 Gel electrophoresis: used to detect abnormal
hemoglobin such as HbS
 Commb’s Test: used to diagnose
immunohemolytic anemias
 Reticulocyte counts; used to distinguish
between anemias caused by red cells
destruction(hemolysis) and depressed
production (marrow failure)
 Iron indices (serum iron, serum iron-binding
capacity, transferring saturation and serum
ferritin concentration) used to distinguish
between hypochromic microcytic anemias
caused by iron deficiency, anemia of chronic
disease and thalassemia minor
 Serum and red cell folate and vitamin B12
concentrations: used to identify the cause of
megaloblastic anemia
 Plasma unconjugated bilirubin and
haptoglobin concentrations: used to support
the diagnosis of hemolytic anemia
 In isolated anemia, tests performed on the
peripheral blood usually suffice to establish a
cause. In contrast, when anemia occurs in
combination with thrombocytopenia and/or
granulocytopenia, it is a much more likely to
be associated with marrow aplasia, or
infiltration; in those instances, a marrow
examination if often critical for diagnosis
Polycythemia
 Polycythemia or erythrocytosis denoted an
increase in the blood concentration of red
cells, which usually correlates with an
increase in the hemoglobin concentration.
 Relative polycythemia results from
dehydration such as prolonged vomiting,
diarrhea or excessive use of diuretics
 Absolute polycythemia can be primary or
secondary
Pathophysiologic Classification of
Polycythemia
Relative
Reduced plasma volume
(hemoconcentration)
Absolute
Primary: Abnormal proliferation of myeloid
stem cells, normal or low erythropoietin
levels (polycythemia vera); inherited
activating mutation in the erythropoietin
receptor (rare)
Secondary: Increased erythropoietin levels
Appropriate: lung disease, high-altitude living,
cyanotic heart disease
Inappropriate: erythropoietin-secreting
tumours(e.g.renal cell carcinoma, hepatoma,
cerebellar hemangioblastoma)surreptitious
erythropoietin use (e.g., in endurance
athelets)
White Cell Disorders
 Disorders of WBCs include deficiencies
(leukopenias) and proliferation which
may be reactive or neoplastic.
 Reactive proliferation is fairly common
 Neoplastic disorders, though less
common are often omnious, 9% of all
cancer death and a stggering 40% in
children younger than 15 years
Causes of Leukocytosis
Neutrophilic Leucocytosis: Acute bacterial
infection particularly pyogenic organisms,
tissue necrosis such as burns and
myocardial infarction

Eosinophilic Leukocytosis (Eosinophilia):

Allergic disorders such as asthma, hay fever,
allergic skin diseases like dermatitis
herpetiformis, parasitic infestations, drug
reaction, some vasculitis
Basophilic Leukocytosis (Basophilia) Rare.
Chronic myeloid leukemia
Lymphocytosis: Tuberculosis, brucellosis, viral
infection, Bordetella pertussis infection
Monocytosis: Chronic infection like
tuberculosis, bacterial endocarditis, malaria,
collagen vascular diseases, inflammatory
bowel disease like ulcerative colitis
Leukopenia: less common, immune deficiency
such as advanced AIDS, treatment with
corticosteroids (lymphopenia)
Leukopenia
 Leukopenia is most commonly
granulocytopenia.
 Lymphopenia is much less common and
are associated with immunodeficiency
disease including HIV infection or
treatment with corticosteroids
Neutropenia/Agranulocytosis
 A reduction in the number of granulocytes
in blood is known as neutropenia or some
times, when severe, as agranulocytosis.
 Usually reduced to 1000 cells/micro L and
in some time as few as 200 to 300
cells/micro L.
 Affected person are extremly susceptible
to bacterial and fungal infections and can
cause death
Two mechanism can cause neutropenia
1. In adequate or ineffective granulopoiesis:
Generalized marrow failure like aplastic anemia,
in variety of leukemia, cancer chemotherapy.
Isolated neutropenia with committed granlocytic
precursors being affected. Can be caused by
drugs or uncommonly by cytotoxic T and NK
cells
2. Acclerated removal or destruction of
neutrophils: Immune mediated injury to
neutrophils by drugs or idiopathic. Increased
peripheral utilization in overwhelming infection.
Splenomegaly can lead to sequestration and
removal of neutrophils
Morphology:
 Changes in bone marrow depends on
underlying basis. Hypercellular in increased
peripheral destruction, ineffective
granulopiesis such as megaloblastic anemia.
Isolated neutropenia may be due to marked
decrease in maturing granulocytic
precurosors in the marrow. Marrow can
hypocellular and all elements can be
supressed
Clinical course in Neutropenia/agrnulocytosis:
 Malaise, chills and fever, weakness and
fatigbility. Infection. Ulcer in oral cavity,
pharnyx.
 Removal of the offending drugs, control of
infections and administration of CSF.
Infectious mononucleosis
 An acute, self-limited disease of
adolescents and young adults caused by
Epstein Barr Virus (EBV)
 Infection is charcterized by fever, sore
throat, generalized lymphadenopathy,
atypical lymphocytosis, antibody and T cell
response to EBV.
 CMV can also cause similar disease which
can be differentiated only serolgical
methods
 EBV is ubiquitous in all human population
 In poorer societies, infection is at early life
and nearly universal. Symptomatic disease is
uncommon, more than half of the affected
people shed virus
 In developed societies, adolescence and
young adult affected, only 20% shed the virus;
only 50 % exposed get infected. Transmission
can occur through kissing. Oropharngeal
epithelial cells and lymphoid B cells harbor
virus. Either viral replication or non productive
viral persistance in episome occurs
 B cells that are latently infected with EBV
undergo polyclonal activation and
proliferation and secrete several antibody
including heterophil anti-sheep red cell
antibody.
 Ig M and later Ig G antibody is produced
 Polyclonal B cell proliferation is controlled by
CD8+ T cells and NK. Cells
 Virus specific cytotoxic T cells appear as
atypical lymphocytes in the circulation, a
finding that is characterstic of acute
mononucleosis
 Latent EBV remains in a few B cells an
possibly oropharyngeal epithelial cells as well.
 Impaired immunity in the host can have
diastrous consequences
Morphology:
Leuckocytosis 12,000 to 18,000/micro L. More
than half are are large atypical lymphocytes
12 to 16 micron with abduant cytoplasm and
often contain azurophilic granules, an oval,
indented or folded nucleus. They are cytotoxic
CD8+ T cells.
 Generalized lymphadenopathy. Paracortical
hyperplasia and can mimick Hodgkin’s
lymphoma
 Spleen is enlarged. Weighs 300 to 500 gm.
Atypical lymphocytes infiltrates. Such spleen
are fragile and prone to rupture after even
minor trauma
 Liver function is transiently impaired. Atypical
lymphocytes in portal areas and sinusoids.
Isolated cell necrosis can be seen. Mimicks
viral hepatitis
Clinical course of Infectious Mononucleosis:
Besides typical presentation mentioned earlier,
atypical presentation are not unusual. Can
mimick lymphoma. Can present as PUO.
Can mimic viral syndromes . Febrile rash as
in rubella can occur.
Diagnosis depends on atypical lymphocytes,
positive monospot test, rising titre of
antibodies to EBV antigen.
Usually resolves in 4 to 6 weeks. Some time
hepatic dysfunction, fatal splenic rupture and
complication in CNS can occur
 In people lacking T cell immunity, polyclonal
B cell proliferation can turn into B cell
lymphoma. EBV is implicated in Burkitt’s
lymphoma and Hodgkin’s lymphoma.
 In X-linked lymphoproliferative syndrome ,
the affected boys due to mutation of SH2D1A
gene which encodes a signaling protein in
the activation of T cells and NK cells,
exposure to EBV, 50% boys dies due to
overwhelming infection, rest develops
lymphoma or hypogammaglobuinemia
Leukemias
 Leukemias are malignant neoplasms of
the hematopoietic stems cells arising in
the bone marrow, that flood the circulating
blood or other organs
 Acute leukemias are characterized by the
presence of immature (blasts) cells and
rapid fatal course in untreated patients
 Chronic leukemias are relatively indolent
and associated with differentiated cells
Classification of Leukemia
 Acute lymphoblastic leukemia(ALL)
 Acute myeloid leukemia(AML)
 Chronic myeloid leukemia(CML)
 Chronic lymphatic leukemia (CLL)
 In acute leukemia, accumulation of blasts
associated with failure of maturation
 The principal pathogentic problem in
acute leukemia is a block in
differentiation
 Normal bone marrow elements are
suppressed and pancytopenia can result
Clinical Features of Acute Leukemia
 Abrupt stormy onset
 Symptoms related to depression of
normal marrow function
 Fatigue due to anemia, fever and
infection due to decreased mature
leucocytes, bleeding (petechiae,
ecchymoses, expistaxis, gum bleeding)
due to thrombocytopenia. Bone pain and
tenderness can occur
 Bone pain and tenderness due to
marrow expansion and infiltration of the
subperiosteum
 Generalized lymphadenopathy,
hepatosplenomegaly and central nevous
system manifestation - meningeal
infiltration are known to occur (more
pronounced in ALL)
 Laboratory finding: Anemia, thrombocytopenia,
Total WBC count less than 10,000 to 100,000
per cmm. Immature Blasts constitute 60 to
100%.
Acute Lymphoblastic Leukemia (ALL)
Primarily a disease of children and young adult
Peak incidence around 4 years
Lymphoblasts have enlarged nuclei with coarse
clumped chromatin with 1 or 2 nucleoli.
Cytoplasm can show PAS positive material. L1,
L2, L3 types of blasts can be recognized
Lymphoblasts versus Myeloblasts
 Coarse chromatin of  Fine chromatin of
nucleus nucleus
 Nucleoli are fewer and  Nuceloli are more and
less conspicuous more conspicous
 PAS positive  Cytoplasm is more and
 Peroxidase negative exhibits fine granules
 Peroxidase positive
 Auer rods may be seen

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

I. AML with Recurrent chromosomal

translocation

AML with t(8;21); CBFa/ETO fusion Favourable

AML with inv(16); CBFb/MYH11 Favourable
AML with t(15;17) PML/RARa Favourable
AML with t(11q23; variant) Poor
II AML with Multilineage Dysplasia
with prior myelodysplastic syndrome Very poor
Without prior myelodysplastic syndrome Poor
III AML, Therapy-Related
Alkylating agent related Very poor
Epipodophyllotoxin related Very poor
IV AML, Not Otherwise Classified
Subclasses defined by extent and type Intermediat
of differentiation (M0-M7) e
Immunophenotype:
 Expression of immunological markers is
heterogenous in AML
 Most express some combination of
CD13,CD14,CD15,CD64,CD117 (cKIT)
and CD33
 Monoclonal antibodies reactive platelets
associated antigens are helpful in the
diagnosis of M7- acute
megakaryoblastic leukemia
 Prognosis: AML is a devastating
disease. Good risk karyotypic aberration
t(8;21), inv(16) are associated with 50%
chance of long term disease free
survival
 Increasing patients are treated with
more aggressive approaches like
allogeneic bone marrow transplantation
Chronic Myeloid Leukemia(CML)
 CML is a clonal disorder of pluripotent stem
cell
 Affects adults between 25 and 60 years.
Peak incidence in the fourth and fifth
decades
 Elevated WBC count more than
100,000/cmm. Predominatly neutrophils
and metamyelocytes. Basophils ,
eosinophils and thrombocytes are
increased. Myeloblasts less than 10%
 CML has total lack of alkaline phosphtase in
granulocytes and 90% cases positive for
Philadelphia t(9;22) chromosome bcr-c-abl
rearrangement
 Clinical symptoms: weakness, weight loss
and huge splenomegaly
 Acclerated phase (10 to 20% blastsand then
blast crisis(more than 20% blasts). Both
myeloid and lymphoid blast crisis can occur
 Median survival 3 to 4 years
 CML is uniformly associated with the
presence of an acquired genetic
abnormality, a BCR-ABL fusion gene.
 95% of cases due to t(9;22) – Philadelphia
chromosome
 Remaining 5% of cases, the BCR-ABL
fusion is created by rearrangements that
are cytogenetically cryptic or obscured.
 BCR-ABL fusion is present in granulocytic,
erythroid, megakaryocytic and B cell
precurosrs – a firm evidence that CML
orginates from pluripotent stem cells
 Although Ph chromosome is highly
characteristic of CML, it should be
remembered that it is also present in
25% cases of adult ALL and rarely in
AML
 BCL-ABL tryosine kinase generates
constitutive signals that mimick the
effects of growth factor receptor
activation
 Granulocyte precursors are more
affected and CML progenitors retain the
capacity for terminal differentiation
CML – Peripheral Blood Film
Massive Splenomegaly in CML
 The red pulp of the enlarged spleen has
an appearance that resembles bone
marrow because of extensive
extramedullary hematopoiesis. Spelnic
infarct can occur due to compromised
local blood supply because of
burgeoning mass of hematopoietic cells
Clinical features in CML:
 On set is slow and often non specific
 Dragging sensation in the abdomen
cause by extreme splenmegaly
 Course of CML is one of slow progression
 Median survival is 3 to 5 years
 Acclerated phase and then full blast
crisis, in another 50% cases blast crisis
abruptly
 30% pre-B cell type of ALL and rest AML
 Myelofibrosis can suprevene
CML versus Leukamoid reaction
 Neoplastic process of  Extreme leuckocytosis
pleuripotential myeloid with shift to left in
stem cells response to infection,
 LAP score is decreased stress and chronic
 Philadelphia inflammation
chromosome is positive  Leukocyte Alkaline
Phosphtase (LAP) score
is increased
 Philadelphia
chromosome is negative
CML Leukamoid reaction
Treatment of CML
 Palliative gentle chemotherapy did not
prevent the development of blast crisis
 Bone marrow transplantation is curative
in 70% of cases
 Gleevec (imantinib mesylate) is useful in
stable phase of CML
Chronic Lymphocytic leukemia
 Most indolent of all leukemias
 Common in western world, uncommon in
Asia
 95 to 99% of neoplasm of mature B cell. T
cell origin can occur.
 Same as SLL , called as CLL if
lymphocytosis is more than 4000 per cmm
 Absolute lymphocytosis of small, mature
looking lymphocytes.
Chronic Lymphocytic Leukemia
Pathophysiology:
 Normal B cell function is depressed,
often resulting in
hypogammaglobulinemia
 15% of patients have autoimmune
hemolytic anemia (paradoxically)
 In the terminal phase anemia,
neutropenia and thrombocytopenia
occurs
 Positive for B cell markers such as CD19,
CD20, CD79a. Positive also for CD5, CD23
and CD43
 Clinical features: Often asymptomatic, non
specific symptoms like fatigue, weight loss
and anorexia. Generalized lymphadenopathy
and hepatosplenomegaly can occur. Total
leuckocyte count can reach 200,000/microL.
 Prognosis: Variable, depends on stage,
anemia and thrombocytopenia. Median
survival 4 to 6 years. Blast crisis does not
occur.
 Karyotypic abnormalities include trisomy
12 and deleetions of chromosome 11
and 12.
 Most CLL/SLL have undergone somatic
hypermutation of their immunoglobulin
segments, a finiding consistent with an
origin from post follicular center B cell,
possible a memory cell
 Tumors derived from naïve B cells have
substantially worse prognosis
Myelodysplastic Syndromes
 Bone marrow is partly or wholly replaced by
the clonal progeny of a transformed
multipotent stem cell with ineffective and
disordered differentiation into red cells,
granulocytes and platelets
 Bone marrow is hyper or normocellular but
the peripheral blood shows one or more
cytopenias
 The stem cell is genetically unstable, and
with additional mutation develop into AML
 Most cases are idiopathic but some develop
after chemotherapy or ionizing radiation
 Some common karyotypic abnormalities
include loss of chromosome 5 or 7, or
deletion of 5q or 7q
 Marrow shows megaloblastoid erythroid
precursors, ringed sideroblasts, granulocyte
precursors with abnormal granules or
nuclear maturation and small
megakaryocytes with single small nucleoli
 Affected indiviudal are between 50 and 70
years
 AML develops in 10% to 40%
 Suffer from infections, anemia and hemorrhage
 Response to chemotherapy is more
 Some time aplastic anemia develops into
myelodysplastic syndrome, myelodysplasia
may responds to immunosuppressants in
these cases
 Prognosis is variable. Survival time is 9 to 29
months
Chronic Myeloproliferative Disorders
 Marked by the hyperproliferation of
neoplastic myeloid progenitors that retain the
capacity for terminal differentiation
 There is increase in one or more formed
elements of the peripheral blood
 Hepatosplenomegaly caused by neoplastic
extramedullary haematopoiesis
 Mutated Tyrosine Kinases which generate
high intensity constitutive signal (response to
Gleevec)
Chronic Myeloproliferative Disorders include
four diagnostic entitites
1. Chronic myeloid leukemia
2. Polycythemia vera
3. Primary myelofibrosis
4. Essential thrombocythemia
Myeloproliferative disorders are associated with
an abnormal increase in the activity of one or
another tyrosine kinase, which appears to
stimuate the same singaling pathways that
are normally activated by hematopoietic
growth factors
 Mutations of the JAK2 kinase are the single
most common genetic abnormality in this
group.
 Seen in .90% of cases of polycythemia vera,
50% of primary myelofibrosis and 30% of
essential thrombocythemia
Myeloid metaplasia with Primary
Myelofibrosis
 Spent phase of marrow fibrosis supervenes
early in the disease course, often following a
brief period of increased WBCs and platelets
in peripheral blood
 Marrow is fibrotic and extramedullary
hematopoiesis occur in spleen, liver and
lymph nodes with extreme splenomegaly and
hepatomegaly
 Hematopoiesis is ineffcient resulting in anemia
and thrombocytopenia in most patients
 Marrow fibrosis is secondary to
derangements of megakaryocytes
 Marrow fibroblassts are stimulated to
proliferate by PDGF and TGF beta released
from neoplastic megakaryocytes
 JAK2 mutation occur in around half of cases
 Overlap occur with other myeloproliferative
disorders
 Perhaps JAK2 mutation occurs in a different
stem cell population in primary myelofibrosis
 Principal site of the extramedullary
hematopoiesis is spleen which is markedly
enlarged, some time up to 4 kg. Subcapsular
infarct are often present in spleen. Spleen
contains normoblasts, granulocyte
precursors and megakaryocytes which are
often prominent in terms of their number and
bizarre morphology
 Bone marrow in a typical case is hypocellular
and diffusely fibrotic. In early cases it is
hypercellular. Megakaryocytes are often
prominent and usually dysplastic
Blood picture in Primary Myelofibrosis:
Most patients have anemia
WBC count is markedly increased, but some
time normal or decreased
Platelets are initially increased and then
decreased
RBC shows poikiocytes – tear drop cells
Nucleated RBCS are seen in the blood
Immature white cells and basophils are
increased
Leukoerythroblastic picture
 Platelet are often abnormal in size and
shape and defective in function
 Peripheral smear picture can mimick CML
but Ph chromosome is absent
 Out come is variable but the median survival
time is 4 to 5 years.
 Constant threat of infections, as well as
thrombotic and hemorraghic spisodes
stemming from platelet abnormalities
 5 to 15% of cases can develop blast crisis
Polycythemia Vera(PCV)
 Hall mark of PCV is the excessive
neoplastic proliferation and maturation
of erythroid, granulocytic and
megakaryocytic elements, producing
panmyelosis
 Clinical signs and symptoms are related
to absolute increase in red cell mass
 PCV is associated with low levels of
erythropoietin in the serum
 Mutation of JAK 2 is seen nearly in all cases,
leads to erythropoietic receptor
hypersensitive to erythropoietin
Morphology:
 Increased blood volume and viscosity
 Plethoric congestion of all tissue or organs is
charcterstic
 Liver and spleen(mild) is enlarged
 Increased viscosity and vascular stasis leads
to thrombosis and infarction in heart, spleen
and kidney
 Hemorrhage occur because excessive
distentionof blood vessels and abnormal
platelet function. Occur in GIT, oropharynx
and brain
 Basophils are increased in the peripheral
blood
 Marrow is hyper cellular due to panmyelosis
 Marrow fibrosis can occur
Clinical Course: PCV appear insidiously, usually
in late middle age. Intense pruritis can occur.
Thrombotic and hemorrhagic tendencies and
hypertension are features
 Headache, dizziness, GIT symptoms,
hematemesis and melena are common.
 Symptomatic gout can occur
 Hematocrit is 60%. WBCS and platelets are
increased. Platelet functions are abnormal
 Thrombotic complications like Budd-Chiari
syndrome and hemorrhage are features
 Marrow fibrosis and blast crisis supervene
 Targeted molecular therapy with JAK2
inhibitors is presently under consideration
Langerhans Cell Histiocytoses
 Tumors of Langherhan cells which are
positive for CD1 antigen and HLA-DR
positive.
 Show classical Birbeck granules under EM
Three forms are described
Unifocal Langerhans cell histiocytosis
Multifocal Langerhans cell histiocytosis
Acute disseminated Langerhans cell
histiocytosis (Letterer-siwe disease)
 Both unifocal and multifocal Langherhan cell
histiocytosis (eosinophilc granuloma) causes
expanding, erosive lesions in bone –
calvarium, ribs and femur are most
commonly affected. Lesion can occur in skin,
lungs or stomach either as unifocal lesion or
multifocal lesions
 Unifocal lesions affect skeletal system. May
be asymptomatic or cause pain and fracture.
Indolent disorder
 Multifocal Langerhans cell histiocytosis
usually affects children who present with
fever, diffuse eruptions particulary in the
scalp and early canals, frequent bouts of
ottitis media, mastoidits and upper
respiratory tract infection.
Lymphadenopathy, hepatosplenomeglay can
occur. In 50% cases posterior pituitary stalk
is affected leading to diabetes insipidus.
Hand-Schuller-Christain triad refers to
calvarial bone defects, diabetes mellitus and
exopthalmos
 Acute disseminated Langerhans cell
histiocytosis (Letterer-Siwe disease) usually
occurs in children less than 2 years of age.
 Dominant clinical feature is the development
of multifocal cutaneous lesions resembeling
seborrheic skin eruptions. Most of the patient
have concurrent hepatosplenomegaly,
lymphadenopathy, pulmonary lesions and
eventually destructive bone lesions. Bone
marrow infiltration leads to anemia,
thrombocytopenia and recurrent infection
such as ottitis media and mastoiditis
 Clinical picture may resemble that of an
acute leukemia
 If not treated, rapidly fatal
 With intensive chemotherapy, 50% patient
surive 5 years

Microscopic picture of Langherhan cell

histiocytosis: Proliferation of mononuclear
cells with grooved nuclei, mixed eosinophils
and giant cells. CD1a positive. C68 and
S100 positive.
Bleeding Disorders
Causes
 Abnormality in blood vessels
(increassed fragility of blood vessels)
 Abnormality in platelets
 Abnormality in clotting cascade
 Bleeding tie: Normal 2 to 9 minutes.
Abnormal in defects of platelet number
and function.
 Platelet count: 150,000 to 450,000/cmm
 Prothrombin time (PT): Tests the
adequacy of extrinsic and common
coagulation pathways. Represents time
needed for plasma to clot in the
presence of exogenously added source
of thromboplasin. Prolonged PT due to
deficiency of factors V,
VII ,X,prothrombin and fibrinogen
 Partial thromboplastin time (PTT); This test
is designed to assess the integrity of the
intrinsic and common clotting pathways. In
this test the time needed for the plasma to
clot in the presence of kaolin, cephalin and
calcium is measured. Kaolin serves to
activate the contact-dependent factor XII,
and cephalin substitute platelet
phopholipids. Prolongation of PTT can be
caused by deficiency of factors V, VII,IX,
X,XI or XII or prothrombin or fibrinogen or
an acquired inhibitor that interfers with the
intrinsic pathway
 Additional test to assess the levels of
specific clotting factors, fibrinogen and
fibrin split products, assess the
presence of circulating anticoagulants
and evaluate platelet function
Causes of Increased fragility of blood
vessels
 Severe vitamin C deficiency (scurvey)
 Systemic amyloidosis
 Chronic glucocorticoid use
 Infectious and hypersensitive vasculitis
meningococcemia, infective
endocarditis, rickettsial diseases,
typhoid, Henoch-Schonlein purpura
 Rare inherited conditions affecting the
connective tissue
 Clinical features: Spontaneous
appearance of petechiae and
echymoses in skin and mucous
membrane. Bleeding time is prolonged,
the other laboratory test of coaguation
are normal
 Deficiency of platets can be quantitative
(thrombocytopenia) or qualitative
 Qualitative platelet disorders can be
inherited lie von Wilebran disease,
Glanzman thrombasthenia, Bernard-
Soulier syndrome or acquired condition like
uremia, aspiring ingestion and in certain
myeloproliferative disorders
 Clinical features: Easy brusing,
nosebleeds, excessive bleeding from minor
trauma and menorragia. PT and PTT are
normal but the bleeding time is prolonged
 Bleeding diatheses purely on a
dearagement of blood clotting factor
differ in several respects from defect in
the blood vessels or platelets. PT, PTT
or both are pronged where as bleeding
time is normal. Petechiae is usually
absent. Massive hemorrhage can occur
after trauma or operative procedure.
Joint hemorrage is common. Example:
Haemophilia
Thrombocytopenia
 Thrombocytopenia is characterized by
spontaneous bleeding, a prolonged
bleeding time and a normal PT and PTT.
Platelet count is 100,000 cells/micro L or
less.
 Spontaneous bleeding occur when
count is less than 20000/microL
 Count of 20000 to 50000/microL –
increased risk of post traumatic bleeding
 Petechiae or large echymoses occur in
the skin or mucous membrane. Large
hemorrages into CNS is a major hazard
in marked thrombocytopenia
 Thrombocytopenia is one of the most
common hematologic manifestation of
AIDS
 Bone marrow examination helps to
differentiate thrombocytopenis due to
decreased production and increased
destruction
Causes of Thrombocytopenia
Decreased Production of Platelets
 Generalized diseases of bone marrow like
aplastic anemia, marrow infiltration in
leukemia or disseminated cancer
 Selective impairment of platelet production.
Drug induced: alchohol, thiazides, cytotoxic
drugs. Infections like measles, HIV infection
 Ineffective megakaryopoiesis:
Megaloblastic anemia, PNH
Decreased Platelet Survival
 Immunological destruction: Autoimmune:
ITP, SLE; Isoimmune: post transfusion,
neonatal; Drug-associated: quinidine,
heparin, sulfa compounds; Infections:
Infectious mononucelosis, HIV, CMV
 Nonimmunological destruction: DIC,
TTP, Giant hemangiomas,
microangiopathic hemolytic anemia
Sequestration: Hypersplenism
Dilutional: HIV
Immune Thrombocytopenic Purpura
(ITP)
 Can occur in a variety of conditions
 Can be idiopathic or primary
 Two clinical subtypes acute ITP and
chronic ITP
 Acute ITP is self limited, common in
children subsequent to viral hepatitis
 Chronic ITP: relatively common, affect
adult females between 20 to 40 years
 Antiplatelet immunogloublin directed
against platelet membrane glycoproteins
IIb/IIIa or Ib/IX complexes are present in
80% of cases
 Spleen is an important site of antiplatelet
antibody production as well as
destruction
 Splenectomy is beneficial
 However spleen is not marked enlarged.
 Bone marrow shows increased
megakaryocyte production
 On set of chronic ITP is insidious.
Petechiae, easy brusiability, epistaxis,
guma bleeding is common
 Diagnois rests on clinical features,
presence of thrombocytopenia,
examination of BM, exclusion of
ssecondary ITP. Reliable clinical test for
antiplatelet antibodies are not widely
available
Heparin-induced thrombocytopenia
 3 to 5% of patients develop
thrombocytopenia treated with
unfractinted heparing after 1 to 2 weeks
 Caused by IgG antibodies that bind to
platelet factor IV on platelet surfaces in
a heparin-dependent fashion.
 Activates platelet aggregation and cause
both venous and arterial thrombosis and
morbidity can be severe
Thrombotic microangiopathies
Includes
Thrombotic thrombocytopenic purpura
(TTP)
Hemolytic-uremic syndrome (HUS)

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