myeloproliferative neoplasm guan hongzai department of hematology e-mail: [email protected]...
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Myeloproliferative Neoplasm
Guan HongzaiGuan Hongzai
Department of HematologyDepartment of Hematology
E-mail: [email protected]: [email protected]
(MPN)
INTRODUCTION
The MPN are clonal haematopoietic stem cell diso
rders characterized by proliferation of one or more o
f the myeloid lineages (i.e. granulocytic, erythroid, m
egakaryocytic and mast cell) .
Initially, MPN is characterized by hypercellularity
of the BM with effective haematopoietic maturation a
nd increased numbers of granulocytes, red blood ce
lls and/or platelets in the PB.
INTRODUCTION
Splenomegaly and hepatomegaly are common
and caused by sequestration of excess blood cell
s or proliferation of abnormal haematopoietic cell
s. Despite an insidious onset each MPN has the p
otential to undergo a stepwise progression that te
rminates in marrow failure due to myelofibrosis, i
neffective haematopoiesis or transformation to an
acute blast phase.
Common characteristics of MPD
1. Derive from the pathologic changes of multipotential stem cells
2. Accompanied with proliferation of one or more cell lineage(s).
3. Reciprocal transformation and concurrent with each other （1.ppt）.
4. Extramedullary hematopoiesis and hepatosplenomegaly.
5. Cytomorphologic abnormalities in peripheral blood.
MPN include: Chronic myelogenous leukemia ( CML)
Chronic neutrophilic leukaemia (CNL)
Chronic eosinophilic leukaemia (CEL)
Primary Myelofibrosis ( PMF )
Polycythemia vera ( PV )
Essential thrombocythemia ( ET )
Hypereosinophilic syndrome(HES)
Mastocytosis
Myeloproliferative neoplasm, unclassifiable(MPN-U)
Primary Myelofibrosis ( PMF )
Objective
• Definition
• Etiology and pathogenesis
• Clinical features
• Laboratory findings
• Diagnosis and differential diagnosis
Definition
Primary myelofibrosis ( PMF), also known as m
yelosclerosis (or agnogenic myeloid metaplasia), i
s a clonal myeloproliferative neoplasm (MPN) cha
racterized by a proliferation of predominantly meg
akaryocytes and granulocytes in the bone marrow
(BM) that in fully developed disease is associated
with reactive deposition of fibrous connective tiss
ue and with extramedullary haematopoiesis (EMH).
There is a stepwise evolution from an initial prefibr
otic phase characterized by a hypercellular BM wit
h absent or minimal reticulin fibrosis to a fibrotic p
hase with marked reticulin or collagen fibrosis in t
he BM and often osteosclerosis. This fibrotic stage
of PMF is characterized by leukoerythroblastosis i
n the blood with teardrop-shaped red cells, and by
hepatomegaly and splenomegaly.
Definition
The underlying cause is unknown in most PMF, the f
ollowing agents may be reported:
The JAK2V617F mutation may be found in 50% pa
tients in the fibrotic phase.
The stem cell change marrow hematopoietic
disturbance increase of dysmorphic megakaryo
cytes in marrow release of cytokines ( PDGF, EC
GF, TGF-β ) stimulate proliferation of fibroblast
fibrous tissue accumulation.
Etiology and pathogenesis
Clinical Features
1. PMF usually occurs after age 40, the median
age at diagnosis is 65 years. About ¼ of
patients are asymptomatic at the time of
diagnosis.
2. In symptomatic patients, fatigue, weakness,
shortness of breath, palpitation, weight loss,
night sweats, and bone pain are common
presenting symptoms.
3. Hepatomegaly is detectable in 50% of patient
s, splenomegaly is present in more than 90%
and massive in one-third.
4. Severe anemia and hemorrhage are present in
the advanced stage of the disease.
Clinical Features
Laboratory Findings
1. Blood The peripheral findings that suggest a diagnosis of MF often include:
• RBC
• Normocytic-normochromic anemia is present in most patients.
• Anisocytosis poikilocytosis, tear-drop red cells, basophilic stippling and nucleated red cell are consistently seen in the peripheral blood.
• Reticulocytes usually range from 2% to 5%.
MF blood smear （ petaloid cell)
MF blood smear
MF blood smear
MF blood smear
WBC
1. The total leukocyte count is usually normal or
mildly increase, but may be as high as 100×10
9/L with neutrophilic granulocytosis.
2. Myelocytes and metamyelocytes are present i
n the blood of all patients, along with a low pr
oportion of blasts ( 1%-5%).
3. Neutropilic alkaline phosphatase scores ma
y be elevated in about two-thirds of the pati
ents.
4. Basophils and eosinophils may be slightly i
ncreased.
5. Dysplastic leukocytes(Pelger-huët anomaly)
may be present.
WBC
MF blood smear
MF blood smear
MF NAP stain
Thrombocytes
1. About one-third of patients have elevated platele
t counts, and one-third have mild to moderate thr
ombocytopenia at the time of diagnosis.
2. Giant platelet, abnormal platelet granulation, and
occasional circulating dwarf megakaryocytes are
characteristic features of the disease.
** About 10% of patients may present with pancyto
penia. It is usually associated with intense marro
w fibrosis.
Marrow Aspiration
Marrow aspiration is usually unsuccessful
because of fibrosis ( “dry tap”)
Bone Marrow Biopsy
Marrow biopsy is very important in the diag
nosis of MF. It is often cellular and shows granulo
cytic, megakaryocytic, and erythron hyperplasia i
n the early stage. In intensely fibrotic marrow cell
ularity may be decreased almost replaced by fibro
us tissues and collagen.
MF bone marrow smear
MF bone marrow biopsy Normal bone marrow
MF bone marrow biopsy AA bone marrow biopsy
MF bone marrow biopsy (silver staining )
1. Chromosome abnormalities are evident in
about 50% of the patients such as +8,-
7,del(7q), del(11q), del(20q)and del(13q), but
the ph chromosome is not present.
2. Approximately 50% of patients with PMF
exhibit the JAK2V617F mutation.
Genetics and molecular findings
1. Bleeding time can be prolonged.
2. Dyscontraction of clot.
3. Platelet adhesion and aggregation can be decrea
sed.
4. Elevated serum levels of uric acid, lactic dehydro
genase(LDH) and alkaline phosphatase.
Other Tests
Diagnosis and Differential Diagnosis
Diagnosis
1. Splenomegaly.
2. Circulating immature myeloid cells and (or) nucleated red cells, accompanied with anisopoikilocytosis and tear-drop cell.
3. Bone marrow aspiration: dry tap or hypoplasia.
4. Extramedually hematopoiesis (spleen,liver,lymph nods) .
5. Bone marrow biopsy: diffuse fibrosis （ essential condition ）
Differential diagnosis
Differential diagnosis between MF and CML
MF CML
WBC normal or mild increase >100 109/L
RBC shape teardrop poikilocyte normal anisocytosis
Nucleated RBC more seldom seen
NAP score increase decrease(zero)
Marrow smear dry tap (40%) myelocyte, meta- and stab granulocyte
Marrow biopsy fibers, megakaryocyte myeloid hyperplasia
Ph chromsome negative positive (95%)
BCR/ABL gene negative positive
Polycythemia Vera ( PV )
Introduction
PV is a clonal, chronic, progressive myelopro
liferative disorder, often of insidious onset, char
acterized by an absolute increase in red cell ma
ss and also usually by leukocytosis, thrombocyt
osis, and splenomegaly. The bone marrow is ty
pically hypercellular and exhibits hyperplasia of
myeloid, erythron, and megakaryocyte lineages.
Clinical features
1. PV usually has an insidious onset, most com
monly at the age of 50 – 60 years. Presenting
symptoms include dizziness, headache, eyes
blurred, plethora, pruritus, weight loss, throm
bosis, and gastrointestinal bleeding.
2. Hepatosplenomegaly present in 75% . One thi
rd of patients are hypertensive.
Laboratory Findings
Blood
1. RBC: male>6.5 1012/L; female >6.0 1012/L
Hb: male>180g/L; female >170g/L
Hct: male>0.54; female > 0.50
2. The morphology of RBC are abnormal. Basoph
ilic stippling and polychromatic cells increase
in most patients
2. WBC: (12-30) 109/L, with shift to left. NAP score raised (>100).
3. Platelet count increase in over 50 percent of
patients, it is ranged from(400-500 ) 109/L.
Laboratory Findings
Marrow
1. Bone marrow aspiration may be “dry tap”; The
marrow shows deep red in color.
2. Hypercellularity or moderate hypercellularity w
ith involvement of all lineages in most cases,
marked in erythron, with normal shape.
3. Megakaryocytes increase. Clusters of five or m
ore megakaryocytes may be seen.
Other Examinations
1. Red cell volume increase ( male>39ml/kg; female
> 27ml/kg)
2. Blood viscosity increase (more than 5 — 6 times
than that of normal.)
3. Vitamin 12 and uric acid usually raised.
4. Platelets have a characteristics functional defect.
5. Cytogenetic: clonal abnormalities in 20% of patie
nts: dysploid, hyperdiploid, multiploid.
PV blood smear
PV bone marrow
PV bone marrow
PV bone marrow
PV bone marrow
Diagnosis and differential diagnosis
Diagnosis
The most important diagnostic features are:
1. Splenomegaly and plethora.
2. RBC: male>6.5 1012/L; female >6.0 1012/L
Hb: male>180g/L; female >170g/L
3. RBC volume: male>39ml/kg; female > 27ml/kg.
4. Hct: male > 0.54; female > 0.50
WBC >11 109/L, BPC > 400 109/L, NAP score>100.
BM hypercellular with all lineages, marked in “E”.
5. Secondary erythrocytosis must be rule out.
Diagnostic Criteria: 1+2+3+5 or 1+2+4+5
Differential diagnosis
PV secondary erythrocytosis
Hb and RBC
Hct
WBC N
PLT N
Splenomegaly + -
BM proliferation E, G, Meg E
NAP score N
Serum VitB12 N
EPO /N
Essential Thrombocythemia (ET)
Introduction
ET is a chronic myeloproliferative disorder characterized by a sustained proliferation of megakaryocytes, which leads to increased numbers of circulating platelets.
In addition to platelet counts in excess, this disorder is characterized by profound marrow megakaryocyte hyperplasia, splenomegaly, and a clinical course punctuated by hemorrhagic or thrombotic episodes or both.
Clinical Features
1. Usually develops between ages 50 and 70.
2. Because platelet counts are now often done as a routine, the disorder is being discovered in patients who are asymptomatic.
3. Mild splenomegaly is found in 50-80 percent of patients.
4. Thrombotic complications: Arterial thrombosis occur more frequently than venous. The most common sites of arterial thrombosis involve the cerebrovascular, peripheral vascular, and coronary arterial circulations.
5. Bleeding complications of ET are similar in nature to those seen in platelet or vascular disorders, occurring in superficial locations either spontaneously or after minimal trauma. The most common sites of bleeding are mucosal and gastrointestinal.
Clinical Features
Laboratory Findings
Blood
1. Platelet increase marked (more than 1000 109/L), MPV .
2. Platelet may be large, small, irregular, pale blue staining, hypogranular. Platelets occur always in clusters.
3. Mild leukocytosis mainly in mature granulocyte. NAP score increase.
4. Mild anemia are common.
ET blood smear
ET blood smear
Marrow Aspiration
Marrow shows cellularity with megakaryoc
ytic hyperplasia and masses of platelet debris.
Megakaryoblast, promegakaryocyte, and mic
romegakaryocyte are always be seen with dys
morphology.
ET bone marrow
ET bone marrow
ET bone marrow
ET bone marrow biopsy
Marrow Biopsy
1. Show hypercellularity, mainly in megakaryo
cytes.
2. Megakaryocytes and promegakaryocytes in
crease with paramorphology, nuclear-cytop
lasmic maturation asynchrony and more lo
bed nucleus.
3. Platelets can be seen in tufty. Micromegakaryo
cytes may present in about 40% patients.
4. Hyperplasia of both erythron and myeloid, but
without infiltration of leukemic cells.
Marrow Biopsy
Cytochemical Staining
• ACP, PAS, -ANE:
mature type: slight in color
Megakaryocyte
immature type: deep in color
Other tests: Platelet aggregation: loss (or decr
ease) of responsiveness to epinephrine and
ADP (70% patients ) .
Diagnosis and differential diagnosis
Diagnosis
Commonly, if there is hemorrhage, spleno
megaly, symptoms and signs related to thr
ombosis in clinical, together with the follo
wing laboratory findings, the diagnosis of
ET may be established.
Differential diagnosis
Differential diagnosis between ET and ST
ET ST
Etiological factor uncertain certain
Bleeding and thrombosis common seen seldom seen
Splenomegaly 80% indefinite
BPC >1000 109/L <1000 109/L
M and function of PLT abnormal normal
WBC increase normal
Megakaryocyte marked increase increase
Megakaryocytic volum enlargement decrease
Life span of platelet normal or short normal
SUMMARY
Morphologic patterns of the myeloproliferative disorders
Disease Morphologic Characteristics
Polycythemia vera Increase in RBC, granulocyte and platelet, mainly in RBC
Increase in three lineages but marked in erythron
Essential thrombocythemia Normal RBC, WBC increase marked increase in platelet count, marrow
megekaryocytes with dysmorphia
Idiopathic myelofibrosis Moderate to marked normocytic anemia with nucleated red blood cells and
“teardrop” form. Marrow fibrosis Increase in megakaryocyte
Review questions
• Define the terms: MPD, PV, ET, MF
• Answer the following questions
• What are the common characteristics of MPD?
• What are the main laboratory findings in PV(ET,MF)?
• How is PV (ET, MF) diagnosed?
• What is the value of the bone marrow biopsy in MF?
Infectious Mononucleosis (IM)
Definition
IM is an acute self-limited benign illness characterized by l
ymphocytosis in respone to infection. Typically, more than 50
% of the blood white cells are lyphocytes, of which at least 10
percent are atypical. The most common cause of IM is EB viru
s. Patients with IM generally with fever, angina, lmpadenopath
y, hepatosplenomegaly. About 90% of IM patients have hetero
phil antibodies.
Etiology: EB virus is the etiologic factor of IM.
Clinical Features
IM affects persons of all ages, but most cases occur in
teenagers and young adults; it rarely occurs in very young
children and person over 40 years of age. Males are
affected more frequently than females.
Commonly see
Constitutional symptoms-- malaise, fever, headache
Sore throat
Superficial lymph node enlargement
Less common
Skin rash, Jaundice, Abdominal pain
Laboratory Findings
Blood
RBC, Hb, Platelet are normal
WBC is normal or increase (10-30109/L) mainly in neutro
phils in the early stage, then an increase in the lymphocyte
s (occupy 60-97%) with atypical lymphocyte (>20%). Atypic
al lymphocyte refers mainly to T-lymphocyte
The abnormal lymphocytes vary in appearance. Downe
y described three type of the cells.
Type -- Plasmocytic or foam type.Ⅰ
These cells vary in size and shape, and are commonly
moderately enlarged. The nucleus, which is eccentrically
placed, may be oval, lobulated or kidney-shaped; the chro
matin is arranged in coarse strands and is irregularly distr
ibuted to give a mottled appearance. Cytoplasm is usually
somewhat more basophilic than in the normal lymphocyte
or as in plasma cell. The cytoplasm is often vacuolated or
foamy and commonly stains less deeply adjacent to the n
ucleus than at the periphery of the cell. Commonly there i
s fine azurophil granulation of the cytoplasm.
Downey Ⅰ
Downey Ⅰ
• Type -- Monocytoid type or irregular typeⅡ
The cells are irregular and more large than
type . Round or slightly irregular nucleus hⅠas dense and small lump chromatin. Cytopla
sm is gray-blue in color and contain some gr
anules.
Downey Ⅱ
Downey Ⅱ
• Type -- Prolymphocytoid typeⅢ
The cell is large with round or oval sha
pe. Round or oval nucleus has delicate re
ticular chromatin with nucleoli sometime
s. Sky blue cytoplasm is moderate with o
r without vacuoles and red-purple granul
es.
Downey Ⅲ
Downey Ⅲ
Bone Marrow
Nonspecific change in most patients.
Lymphocytes increase slightly with few
atypical lymphocytes.
IM bone marrow
IM bone marrow
Serum examination
• Heterophil agglutination test(Paul-Bunell test,P-B test): agglu
tination titer ≥ 1:224
• Heterophil agglutination differential absorption test: positive
• Monospot test: positive
Serum pre-absorption post-absorption post-absorption
(cavy kidney) (ox RBC)
IM ++ + -
Normal + - ±
Serum Patient + - -
+ : non-absorption; - : absorption; ± : partial absorption
•
• Detection of EBV antibody:
The IgM antibody to virus capsid antigen is
a sign of acute infection, persiting for only a fe
w months----essential for the diagnosis.
The IgG antivirus capsid antigen, on the oth
er hand, persist for life --- epidemiological surv
ey
Serum examination
Diagnosis
In typical cases the diagnosis is suspected
from the clinical features such as malaise, fev
er. Sore throat, lymph node enlargement and s
plenomegaly. It is confirmed by the demonstra
tion of the abnormal lymphocytes in the blood
film and by the positive heterophil agglutinati
on test.
嗜异性凝集试验 (Paul-Bunell test, P-B 试验 ) 属于非特异性的血清学试验，用于检测受检者血清中绵羊红细胞凝集素的滴度。正常人为 1:100 ，传单病人等于或高于 1:224 。但少数病人可以不高。某些疾病如血清病、病毒性肺炎、风疹、霍奇金病、白血病或新近用过马血清或马血清免疫制剂者，其血清嗜异性凝集素可增高，可达 1:224以上。
…… 待测血清
0.1ml
2% 绵羊红细胞悬液 0.1ml, 各管浓度为 1:7 、 1:14………..1:336
结果：室温静置 2h ，以出现凝集的最大稀释度作为滴度， IM 一般大于等于 1:224
1 2 10 11 12 13
1#: 生理盐水 0.4ml ，其它各管加 0.25ml 13# ：对照
0.25ml 0.25ml 0.25ml 弃掉
实验方法
鉴别吸收试验
传单病人的红细胞凝集素不被或不完全被 Forssman 抗原吸收，但可被牛红细胞吸收。而其它病人及血清病的绵羊红细胞凝集素可被 Forssman 抗原吸收，根据这一原理，可进行鉴别吸收试验。
嗜异性凝集素的鉴别吸收试验结果
血清来源 吸收前 豚鼠肾吸收后 牛红细胞吸收后传单病人 ++ + –正常血清 + – ± 血清病人 ++ – – + ：未被吸收 – ：已被吸收 ± ：被吸收或部分吸收
本试验的应用范围：1. 临床高度怀疑本病，但嗜异性凝集试验的滴度过低者。2. 临床无本病征象，但嗜异性凝集试验的滴度增高者。3. 新近接受过马血清注射者。
单班试验
该试验 1868 年由 Lee 等人提出，原理与鉴别吸收试验类似。试验中以甲醛化的马红细胞取代绵羊红细胞，使结果更为灵敏；以牛红细胞抗原取代牛红细胞，以免干扰结果观察。
受检血清
豚鼠肾匀浆 牛红细胞抗原
马红细胞悬液（混 匀，静置 2min ）
结果：若豚鼠肾吸收后的血清比牛红细胞吸收后的血清产生的凝集现象强，就支持传单。
单班试验具有高特异性、高灵敏度、只需微量血、试验时间短。
试验方法
EBV 抗体测定：较复杂，但具有特异性（一般用间接免疫荧光法）。
EBV 特异性抗体包括：
1. 抗 VCA-IgM 抗体，约 90%-100% 的病例在病程早期，抗 VCA-IgM抗体效价≥ 1:10 ，在临床发病时即达高峰，持续 4-8 周后消失。抗VCA-IgM 抗体阳性是 IM 急性期诊断的重要指标。
2. 抗 VCA-IgG 抗体，在发病 2 周达高峰，以后以低水平存在并持续终生， IgG 抗体虽不能作为近期感染的指标，但可用作流行病学调查。
3. 抗 EB 核抗原（ EB nuclear antigen, EBNA ）抗体，疾病早期出现，长期存在。
4. 抗早期抗原（ early antigen,EA ）抗体，其弥散性部分于急性期时有80% 阳性，但较短暂。
5. 抗膜抗原（ membrane antigen,MA ）是病毒的中和抗体，恢复期达高峰，但持续终身。
Leukemoid Reaction (LR)
Definition
LR is an abnormal reaction of blood formi
ng organs after the body is provoked by some
disease and other external factors. The blood c
hanges are similar to those of leukemia, but it i
s not leukemia.
Etiology
The causes of LR are always clear, such as in
fection, toxic agents, inflammation and neoplasti
c disorders.
Classification:
• According to total white blood cell, LR may be
divided into increasing and non-increasing type
• According to the course of disease: acute and
chronic
According to the type of cell, LR may be classified as:
• Neutrophilic granulocytic type
( most commonly )
• Lymphocytic type
• Monocytic type
• Eosinophilic granulocytic type
1. Neutrophilic granulocytic type
① Most commonly see in clinical.
② WBC >50×109/L, neutrophils increase markedly ， accompanied with myelocyte, promyelocyte and myel
oblast.
③ NAP score increase markedly.
④ Toxic changes in neutrophils: toxic granulations, pykn
osis ， hyaline degeneration and vacuoles.
⑤ Etiological factors: infections( acute suppurative infect
ion), malignant tumors, organic pesticide or CO intoxic
ation ， acute hemolysis or hemorrhage, large areal bu
rn.
• Neutrophilic granulocytic type (blood smear)
Neutrophilic granulocytic type (bone marrow)
2. Lymphocytic type
① WBC : (20-30) ×109/L , sometimes more than
50 ×109/L
② Lymphocyte >40%, most of which are matu
re lymphocytes, prolymphocye and atypical lymp
hocyte may be seen sometimes.
③ Etiological factors: virus infection ( IM, pertu
ssis, varicella, rubella), miliary tuberculosis, scarl
et fever and syphilis, carcinoma of stomach.
④Lymphoblast and basket cell don’t increase.
Lymphocytic type （ blood smear ）
3. Monocytic type
① WBC: more than 30 ×109/L , less than 5
0 ×109/L
② Monocyte > 30%, promonocyte may be
seen (occasionally)
③ Etiological factors: miliary tuberculosis,
typhus, bacillary dysentery.
• Monocytic type (blood smear)
4. Eosinophilic granulocytic type
① WBC: >20 ×109/L
② Eosinophil > 20%, most of them are matu
re cell.
③ Etiological factors: parasite infection, all
ergic disease, Hodgkin disease.
• Eosinophilic granulocytic type (blood smear)
Laboratory Findings
• Blood
• WBC increase obviously ( 50--100109/L) with mor
phologic abnormalities, such as toxic granules, vacuo
les, karyopyknosis and abnormal mitotic figure.
• RBC: normal
• PLT : normal or increase slightly.
Bone Marrow:
There are no special changes except shift to to left
and toxic granules.
Cytochemical Stain: NAP score increase.
Diagnosis And Differential Diagnosis
LR Leukemia
Etiological factors + –
Clinical features symptom from anemia, bleeding, fever, hapto-
primary disease splenomegaly, lymph node
swelling, leukemic cell infiltration
BLOOD
WBC increase increase (100-200) 109/L
(< 100109/L)
Immature cell immature: <5-15% >30%
blasts 1%-5%
Morphology toxic granules anomaly , Auer body
of WBC or vacuoles
Basophil normal increase in CML
RBC normal decrease progressively with
nucleated cell
Diagnosis And Differential Diagnosis
LR Leukemia
Platelet normal or increase decrease (except early stage of
CML )
NAP marked increase marked decrease in AML
BM myelocytes increase, hyperplasia, accompanied with
shift to left excess blasts and immat
ure cells
Ph1 – 90%CML (+)
Pathologic non-leukemic cell disseminated infiltration of detec
tion infiltration leukemic cells
Therapy rapidly recover relapse easily
reaction
Characteristics of LR
1. Primary lesion cure, LR recover.
2. WBC usually range from 50 –100 109/L (seldom >200
109/L) , mainly in myelocytes and metamyelocyte (gra
nulocytic type : WBC >50 109/L, with more than 2% i
mmature cells; Lymphocytic type: WBC range from 20
–30)109/L ， with more than 40% lymphocytes, most
of them are mature lymphocytes, prolymphocye and a
typical lymphocyte may be seen sometimes; Monocyti
c type: WBC >30 109/L, monocytes >30%); Eosinophil
ic type: WBC >20 109/L, eosinophils >20%).
3. WBC shows dysmorphology such as toxic granules, vacuoles, karyopyknosis and abnormal mitotic figure.
4. Bone Marrow has no special changes except shift to to left and toxic granules.
5. Without leukemic infiltration and extramedullary hematopoiesis in all of the organs.
6. NAP score increase obviously.
7. Without chromosome abnormalities.
Characteristics of LR
LEUKOPENIA
Definition
Leukopenia may be defined as a decrease in the total w
hite blood cells ( < 4 109/L ), especially granulocytes in cir
culatory blood.
Neutropenia refers to the absolute value of neutrophils
are less than 1.5 109/L in children(<10y), 1.8 109/L(10-14
y) and 1.8 109/L in adults.
Agranulocytosis is used to indicating severe neutropen
ia ( <0.5 109/L ), accompanied with clinical expressions, s
uch as acute fever, exhaustion and infection.
Etiology and Pathogenesis
• Proliferation and maturation defect
1. Chemical substances and cytotoxic drugs AA
2. Radiation suppression of multiplication and
division of immature myelocytes.
3. Marrow involvement.
4. Congenital dyshematopoiesis.
• Excess of destruction and Consumption
1. infection of virus and microorganism granulocytes decrease.
2. immunoneutropenia
• autoimmune disease (SLE, CAH)
• drugs induced
3. Mechanical: extracorporeal circulation (ECC)
• Distribution abnormal
Increase in marginal pool ( Pseudogranulocytopenia)
• Release defect (lazy leukocyte syndrome)
Etiology and Pathogenesis
Laboratory Findings
Blood
1. White blood cell is always below 4.0 109/L, th
e absolute of neutrophils below 2.0 109/L, les
s than 0.5 109/L in severe patients.
2. When infection occur, obvious shift to left, tox
ic granules, vacuoles can be seen.
3. Lymphocytes increase, but erythron and meg
akaryocytes may be normal.
Blood smear
Blood smear
Bone Marrow
Defect of production: granulocyte decrease.
Mature suppression: mature cell decrease,
myeloblast and promyelocyte may be seen.
Ineffective granulocytopoiesis:degeneratio
n in immature granulocyte.
Erythron and megakaryocyte are normal or
decrease.
Bone marrow
Bone marrow
Bone marrow
Bone marrow
Bone marrow
Detection of Granulocytic Reserve Pool
Prednisone stimulating test
Detection of Granulocytic Marginal Pool
Adrenine stimulating test
Detection of Leukocytic Antibodies
DF32P label: Life span of granulocyte T1/2: 6-7h
Other tests
LIPOID STORAGE DISEASE
Introduction
Lipoid storage disease is hereditary disorders
（ autosomal recessive ） in which one or more ti
ssues becomes engorged with a lipoid. The type
of lipoid and its distribution have a characteristic
pattern in each disorder. Those disorders are Gau
cher disease, in which glucocerebrosides is store
d, and Niemann-pick disease, where the storage
material is sphingomyelin and/or cholesterol.
Gene mutation hydrolase defect block t
he lipoid hydrolyze lipoid accumulate in histio
cytes of mononuclear--phagocyte system cell enla
rgement (foam cell).
Etiology and Pathogenesis
Guacher Disease
Definition
Gaucher disease is also called Glucocer
ebrosidosis. It is an autosomal recessive i
nherited disorder, characterized by abnor
mal accumulation of glucocerebrosides in
histiocyte.
Laboratory Findings
Blood
RBC count may be normal, but normocytic,
normochromic anemia with modest reticulocyt
osis is often found. Lekopenia and thrombocyt
openia may occur and may be severe.
Marrow
Gaucher cells are large cells found in marrow,
spleen, and liver in varying number. They are cha
racterized by small, eccentrically placed nuclei a
nd cytoplasm with characteristics crinkles or stri
ations. The cytoplasm stains with the PAS, ACP
and SB positive, but POX and NAP negative.
Gaucher cell
Gaucher cell
Gaucher cell
Gaucher cell (spleen print)
Gaucher cell (PAS stain)
Niemann-pick Disease
Definition
Niemann-pick disease also called sphingomyeli
nosis. It is inherited as an autosomal recessive dis
order. The predominant lipoid accumulating in tiss
ues is sphingomyelin.
Laboratory Findings
Blood
Mild anemia may be present(normocytic, nor
mochromic ).
Blood lymphocytes and monocyte typically m
ay be contain small lipid-filled vacuoles.
Leukocytes are deficient in sphingomyelinase.
Marrow
The marrow contains typical foam cells (N-
P) ranging in size from 20 to 80m in
diameter and containing small, gray-blue in
color and uniform droplets throughout the
cytoplasm. The cytoplasm of these cells
stains only very faintly with the PAS, but
the ACP, NAP and POX are all negative.
N-P cell
N-P cell
N-P cell
The differences between Gaucher and N-P cell N-P cell Gaucher cell Shap big 20-100m big 20-80 m
Nucleus only one more
Chromatin loose dense
Cytoplasma rich, see vacuoles, rich, onion peel
contain sphingophoslipid structure, contain
glucocerebroside
PAS vacuoles’ wall (+) +++
vacuoles’ center (-)
ACP - +++