Atlas of Hematology Atlas of Hematology Renu Saxena MBBS, MD (Pathology) Professor and Head Department of Hematology All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi HP Pati MBBS, MD (Pathology) Professor Department of Hematology All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi M Mahapatra MBBS, MD (Internal Medicine) Additional Professor Department of Hematology All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London ® Jaypee Brothers Medical Publishers (P) Ltd. Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P. Medical Ltd., Jaypee-Highlights Medical Publishers Inc. 83 Victoria Street London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: 507-317-0160 Fax: +02-03-0086180 Fax: +50-73-010499 Email: info@jpmedpub.com Email: cservice@jphmedical.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, Jaypee Brothers Medical Publishers Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure a accuracy of information, the publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the authors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Publisher: Jitendar P Vij Publishing Director: Tarun Duneja Cover Design: Seema Dogra Atlas of Hematology First Edition: 2012 ISBN 978-93-5025-508-7 Printed at ® P reface There has been a long felt need for an Atlas of Hematology. With this in mind, our endeavor in this atlas was to give representative clinical photographs and microphotographs of some of the commonly seen hematological disorders. This book is likely to be helpful to pediatricians, internists and pathologists practicing hematology, undergraduates and postgraduates of pediatrics, medicine and pathology, especially in centers where many of these lesions are not commonly seen. We hope this book will be useful to the readers. Renu Saxena HP Pati M Mahapatra a cknowledgments We would like to acknowledge Dr Narender Tejwani DM, Resident, Department of Hematopathology, AIIMS for meticulous proofreading and Mr Harinder Kumar for secretarial help. c ontents Anemias 1 Investigation 1 Hypochromic Microcytic Anemia 1 Sideroblastic Anemia 4 Macrocytic Anemia 5 Dimorphic Anemia 7 Myelodysplastic Syndrome (MDS) 8 Normocytic Normochromic Anemia 15 Chapter One Chapter Two Chapter Three Bone Marrow Failure Syndromes 16 Aplastic Anemia 16 Differential Diagnosis of Pancytopenia 19 Fanconi’s Anemia 20 Paroxysmal Nocturnal Hemoglobinuria (PNH) 22 Pure Red Cell Aplasia (PRCA) 23 Hemolytic Anemias 26 Peripheral Blood Examination 27 Diagnosis of Hemoglobinopathies 31 Common High Performance Liquid Chromatography (HPLC) Patterns 31 Congenital Dyserythropoietic Anemia (CDA) 39 Thalassemia 40 Hereditary Spherocytosis 42 Atlas of Haematology x Chapter Four Chapter Six Chapter Five Disorders of Platelets 43 Thrombocytopenia 43 Primary Immune Thrombocytopenia (ITP) 43 Thrombotic Thrombocytopenic Purpura/HUS 47 Platelet Function Defects 48 Thrombocytosis 49 Acute Leukemia 50 Acute Lymphoblastic Leukemia (ALL) 52 Blast Morphology 52 Acute Myeloid Leukemia (AML) 57 Biphenotypic Leukemia 64 AML with Multilineage Dysplasia 64 Acute Myeloblastic Leukemia/Myelodysplastic Syndrome: Occupation Related or Therapy Related 64 Chronic Leukemia 70 Chronic Myeloid Leukemia (CML) 70 Polycythemia Vera 74 Essential Thrombocythemia 75 Chronic Lymphocytic Leukemia (CLL) 76 Prolymphocytic Leukemia (PLL) 79 Hairy Cell Leukemia (HCL) 80 xi Contents Chapter Eight Chapter Seven Chapter Nine Myelofibrosis 84 Plasma Cell Dyscrasias 88 Monoclonal Gammopathy of Undetermined Significance (MGUS) 88 Smoldering Myeloma 88 Multiple Myeloma 88 Solitary Plasmacytoma of the Bone 91 Amyloidosis 91 Infections 94 Septicemia 94 Hemophagocytosis 95 Malaria 101 Microfilaria 102 Tuberculosis 102 Atlas of Haematology xii Stem Cell Transplant 103 Causes of Marrow Transplantation Failure 105 Post-transplant MDS 106 Chapter Ten Index 107 Anemias 1 C h a p t e r CHAPTER OVERVIEW r Investigation r Dimorphic anemia r Hypochromic microcytic anemia r Myelodysplastic syndrome (MDS) r Sideroblastic anemia r Normocytic normochromic anemia r Macrocytic anemia Anemia is one of the most com- mon clinical presentation. Amongst these, anemia due to nutrient deficiency such as iron, vitamin B 12 or folic acid are very common. Folate deficiency is much more common than B 12 deficiency since liver stores for vitamin B 12 last for five to six years whereas stores for folic acid last for three to four months. Iron deficiency anemia, particularly mild to moderate, may cause a problem in differential diagnosis from other hypochromic anemias like beta th a- lassemia trait, alpha thalassemia trait, Hb E disease, sideroblastic anemia or anemia of chronic disorder. INVESTIGATION For diagnosis of anemia, the follow - ing preliminary investigations are most important: • Hemoglobin, hematocrit (PCV) • Red cell indices: MCV, MCH, MCHC, RDW (with auto - mated cell counters) • Reticulocyte count Based on these tests, anemia subtypes can be made, which helps in reaching a diagnosis (Fig. 1.1). HYPOCHROMIC MICROCYTIC ANEMIA Erythroid cells showing central pallor occupying more than one third the size of red cell are termed hypochro - mic. Peripheral smears with small red cells (microcytes) and hypochromia may be seen in the following: Fig. 1.1: Initial step in the morphologic classification of anemia ( microcytic, macrocytic, normocytic anemia) Atlas of Hematology 2 Iron Deficiency Anemia • Thalassemia/Hemoglobinopa - thy • Sideroblastic anemia • Anemia of chronic disorder A good peripheral smear examination in conjunction with hemogram can help diagnose iron deficiency anemia. Presence of microcytic hypochromic red cells (Fig. 1.2) in the absence of target cells, basophilic stippling suggest untreated iron deficiency espe - cially when it is associated with reactive thrombocytosis. Moreo - ver, unlike thalassemia minor, the red cell changes in iron deficiency manifest only when hemoglobin is less than 10 g/dl. Some times elongated pencil cells are also seen in iron deficiency anemia. There may be associated eosinophilia if iron deficiency is secondary to worm infestation. It may sometimes be difficult to differentiate iron deficiency anemia from anemia of chronic disorder. This may require estimation of bone marrow iron which is assessed on iron stain. Interpretation of bone marrow iron stain is as follows: • Iron deficiency is the most com - mon cause of anemia world - wide • Normal (Western) diet provides approximately 15 mg of iron (Fe)/d, of which five to ten per - cent is absorbed in duodenum and upper jejunum • Total body iron store is≈4 g. Around 1 mg of iron (Fe)/d is lost in urine, feces, sweat and cells shed from the skin and GIT • Iron deficiency is more com - mon in the reproductive age since menstrual losses account for ~ 20 mg Fe/month and in pregnancy an additional 500 to 1000 mg Fe may be lost (transferred from mother to fetus) • In general, iron metabolism is balanced between absorption of 1 mg/d and loss of 1 mg/d. Pregnancy may also upset the iron balance, since require - ments increase to 2 to 5 mg of Fe/d during pregnancy and lactation • Normal dietary iron cannot supply these requirements, and medicinal iron is needed dur- ing pregnancy and lactation. Repeated pregnancy (especially with breastfeeding) may cause iron deficiency if increased requirements are not met with supplemental medicinal iron. Causes of Iron Deficiency • Reproductive system : Menor - rhagia • GI tract: Eso phagitis, esopha- geal varices, hiatus hernia Fig. 1.2: IDA: Microcytic hypochromic 3 Anemias (ulcerated), peptic ulcer, inflam - matory bowel disease, hemor - rhoids, carcinoma: stomach, colorectal, (rarely angiodys - plasia, hereditary hemorrhagic telangiectasia) • Malabsorption: Coeliac disease, atrophic gastritis ( note : may also result from Fe deficiency), gastrectomy • Physiological: Growth spurts, pregnancy • Dietary: Vegans, elderly • Genitourinary system: Hematuria (uncommon cause) • Others: PNH, frequent venesec - tion, e.g. blood donation Worldwide Commonest cause is hookworm infestation Clinical Features • Symptoms of iron deficiency anemia are those of the anemia itself (easy fatigability, tachy - cardia, palpitations and tachyp - nea on exertion). • Severe deficiency causes skin and mucosal changes, includ- ing a smooth tongue, brittle nails and cheilosis. Dysphagia because of the formation of esophageal webs (Plummer– Vinson syndrome) also occurs. In chronic cases, we can see koilonychias (Fig. 1.3). • Many iron-deficient patients develop pica, craving for spe - cific foods (ice chips, etc.) often not rich in iron. Treatment • Oral iron therapy should begin with a ferrous iron salt, taken separately from meals in three or four divided doses and sup - plying a daily total of 150 to 200 mg of elemental iron in adults or 3 mg of iron per kilogram of body weight in children • Simple ferrous preparations are the best absorbed and least expensive. Ferrous sulfate is the most widely used, either as tablets containing 60 to 70 mg of iron for adults or as a liquid preparation for children • Administration between meals maximizes absorption • While the various prepara - tions contain different amounts Fig. 1.3: A patient with chronic iron deficiency anemia with koilonychia Atlas of Hematology 4 of ir on, they are generally all absorbed well and are effective in treatment • An appropriate response is a return of the hematocrit level halfway toward normal within three weeks with full return to baseline after two months • Iron therapy should continue for 3 to 6 months after restora - tion of normal hematologic values to replenish iron stores. Parenteral Iron • Intravenous iron can be given to patients who are unable to tolerate oral iron, whose needs are relatively acute, or who needs iron on an ongoing basis, usually due to persistent gas - trointestinal blood loss • Parenteral iron use has been rising rapidly in the last several years with the rec - ognition that recombinant erythropoietin therapy induces a large demand for iron • Total dose of parenteral iron required is calculated by fol - lowing formula: Body weight (kg) × 2.3 × (15– patient’s hemo - globin, g/dl) + 500 or 1000 mg (for stores) • Iron sucrose (Venofer) or iron dextran prepration are avail - able for intravenous use. Iron sucrose appears to be safer than dextran and no episode of anaphylaxis been reported. Grading Iron Stains in Bone Mar - row Aspirates (Table 1.1) SIDEROBLASTIC ANEMIA It is a heterogeneous group of disorders characterized by anemia of varying severity and diagnosed by finding ring sideroblasts in bone marrow aspirate (Fig. 1.4) defi ned as siderotic granules arranged in a perinuclear collar distribution sur - rounding one-third or more of the nuclear perimeter. Iron overload is the common clinical feature and in severe cases may lead to secondary hemosidero - sis. Classification of Sideroblastic Anemia Hereditary • X-linked • Autosomal dominant or reces - sive Acquired • Idiopathic acquired (RARS) • Associated with previous chemotherapy, irradiation or in ”transitional” MDS or MPNs Drugs • Alcohol Fig. 1.4: Sideroblastic anemia 5 Anemias • Isoniazid • Chloramphenicol • Other drugs Rare Causes • Erythropoietic protoporphyria • Pearson syndrome • Copper deficiency or zinc over - load • Thiamine responsive megalob - lastic anemia • Hypothermia MACROCYTIC ANEMIA This is diagnosed when MCV is greater than 97 fl. MCV >110 highly suggests megaloblastic anemia (MA) whereas < 110 may be seen in aplastic anemia, MDS, liver disease, high reticulocyte count and CDA in addition to megaloblastic anemia. In megaloblastic anemia, peripheral smear may show macrocytes along with fully hemoglobinated macro- ovalocytes, cabot rings, hyperseg - mented polymorphonuclear cells (1/100 PMN with greater or equal to 6 lobes or 5/100 PMNs with 5 lobes) and rarely circulating mega - loblast (Fig. 1.5). Grade Criteria Iron content (ug/g)* 0 No iron granules observed 43 ± 23 1+ Small granules in reticulum cells, seen only with oil-immersion lens 130 ± 50 2+ Few small granules visible with low-power lens 223 ± 75 3+ Numerous small granules in all marrow particles 406 ± 131 4+ Large granules in small clumps 762 ± 247 5+ Dense, large clumps of granules 1618 ± 464 6+ Very large deposits, obscuring marrow details. 3681 ± 1400 Table 1.1: Bone marrow iron positive: Prussian blue stain * Mean ± SD. Fig. 1.5: Peripheral smear from a patient with megaloblastic anemia showing macrocytes and macro-ovalocytes (without central pallor) Atlas of Hematology 6 In cases of doubt, therapeutic response to vitamin B 12 (1000 mg) and 5 mg folic acid for seven days can be assessed by repeating reticu - locyte count which peaks at five to eight days of therapy. Sometimes, macrocytic anemia may be nonmeg - aloblastic. B 12 Deficiency • The hallmark of symptomatic vitamin B 12 deficiency is mega - loblastic anemia. In advanced cases, the anemia may be severe, with hematocrits as low as 10 to 15 percent and may be accompanied by leukopenia and thrombocytopenia • Patients are usually pale and may be mildly icteric • The megaloblastic state also produces changes in mucosal Fig.1.6: Skin pigmentation in megaloblastic anemia cells, leading to glossitis, as well as other vague gastroin - testinal disturbances such as anorexia and diarrhea. Patients can have pigmentation of skins (Fig. 1.6) • Vitamin B 12 deficiency also leads to a complex neurologic syndrome. Peripheral nerves are usually affected first and patients complain initially of paresthesias. The posterior columns next become impaired and patients complain of dif- ficulty with balance • In more advanced cases demen - tia and other neuropsychiatric changes may precede hemato - logic changes. Management of B 12 Deficiency • Identify and correct cause if possible • Vitamin B 12 replacement, 1 mg of intramuscular cyanocobala - min per day (week 1), 1 mg twice weekly (week 2), 1 mg/ week for 4 weeks, and then 1 mg/mo for life. Folic Acid Deficiency Symptoms and signs: Similar to those of vitamin B 12 deficiency with megaloblastic anemia and megalob - lastic changes in mucosa. However, usually there are none of the neuro - logic abnormalities associated with vitamin B 12 deficiency. Management • Folic acid 5 mg/d PO • Treatment of underlying cause, e.g. in coeliac disease folate levels and absorption normal - ize once patient established on gluten-free diet. 7 Anemias Fig. 1.7: Bone marrow aspirate showing megaloblast with large nucleus with sieve like chromatin and deep blue cytoplasm Bone marrow in megaloblastic anemia (Fig. 1.7): This is cellular with eryth - roid hyperplasia showing nucleo - cytoplasmic asynchrony. Various stages of erythroblasts are seen with large nuclei, opened out chromatin and relatively hemoglobinized cyto - plasm (Fig. 1.7). This is associated with presence of giant myeloid forms and dyserythropoiesis. Although presence of early megaloblastoid changes may be seen in reactive BM, MDS, etc. presence of late megaloblast is generally seen in megaloblastic anemia. DIMORPHIC ANEMIA At times IDA coexists with mega - loblastic anemia. It then shows presence of microcytic as well as macrocytic red cells. Sometimes, red cell morphology due to one deficiency predominates over the other. In such a situation, the other deficiency red cell changes manifest after the first deficiency is treated (Fig. 1.8). Fig. 1.8: Dimorphic anemia. Presence of microcytic hypochromic, macro-ovalocytes, suggests a combined IDA with megaloblastic anemia