NPLEX Combination ReviewHematology

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

What does blood do for us?…. And what happens when it goes bad?

• Oxygen carrying– Less is not good!– Fatigue, cognitive dysfunction…

• Immune cell transportation– Proper immune function and surveillance

• Health, brisk immune response– Improper immune cell transportation

• Metastatic disease

• Clotting

• Cytokine and Hormone transportation– Balance of blood proteins / oncotic pressure

• Free –vs- bound hormone and drug• Edema…

– Delivery of cytokines, hormones, drugs, nutrients…• Metabolic homeostasis

• Etc…

Cell Lines

Bone Marrow:

Hemocytoblast

Myeloid Stem

Lymphoid Megakaryocyte

Stem Proerythroblast

Monoblast Myeloblast

B-Cells NK Cells Platelets Retic’s

Peripheral Tissues: PLT RBC’s WBC’s

Cell Mediated Immunity Ab (Humoral) Immunity Immunological Surveillance

Thymus:

Lymphoid Stem Cells

T-Cell Lines

“The Capillary Thoroughfare”

CLOTTING PATHWAYS

Measured by: PTT

Drugs: Heparin

Measured by PT/INR

Drugs: Warfarin, ASA, Vitamin-E, EFA’s

Factors 2-7-9-10

PROTHROMBIN ACTIVATOR made up of V&X: Started by X alone and V becomes active with + feedback

Extrinsic Pathway: Damage outside of blood vessels.

Intrinsic Pathway:

Blood trauma (turbulence and viscosity) or collagen and blood contact.

IRON HANDLING

HEMOGLOBIN - 1• HEME is synthesized, and a protein (globin) added to

form Hemoglobin (Hb)• Hb is a tetramer with 4 O2 binding sites

– Hb has 2 alpha and 2 beta subunits– Each has one O2 binding site

• Hb has one ferrous (Fe2+) molecule at its center• Hb has RELAXED and a TAUT formations

– ‘R’ Hb has 4 open O2 sites– ‘T’ Hb has none

• The ‘T’ form is taken after O2 dumping at peripheral sites• 2,3-Bisphosphoglycerate (2,3-BPG) stabilizes the T-Hb, by forming

salt bridges to bind the beta subunits.

• Myoglobin is an Oxygen storage site in muscle– It is similar to Hb, but binds the O2 more tightly, and will

only let it go under low O2 situations (O2 debt in Muscle).

HEMOGLOBIN - 2

HEMOGLOBIN - 3

HEMOGLOBIN – The Bohr Effect

Hematology Test Normal Range Increased Decreased Interfering Factors

RBC Count Female 3.6-5 x 106/lMale 4.2-5.4 x 106/l

Polycythemia Vera, erythrocytosis

Anemia, blood loss, lymphoma, myeloproliferative disorder, leukemia

Dehydration, age, altitude, pregnancy

Hematocrit(red cell mass)

Female 36-48Male 42-52

Polycythemia Vera, erythrocytosis, dehydration, shock

Anemia, leukemia, acute blood loss

Dehydration, age, altitude, pregnancy

Hemoglobin(blood concentration)

Female 12-16 g/dlMale 14-17.4 g/dl

Polycythemia Vera, severe burns, COPD, CHF

Anemia, hemolytic reactions, hemorrhage, system disease

Altitude, excess fluid, pregnancy, drugs

MCV-Mean Corpuscular Volume

Adults 82-98/l3 Macrocytic anemia Microcytic anemia Normal values in normocytic anemia

MCHC-Mean Corpuscular Hemoglobin Concentration

Adults 31-37 g/dl Spherocytosis Iron deficiency, macrocytic anemia, thamlassemia

Presence of cold agglutinins, lipemia, high amounts of heparin

MCH-Mean Corpuscular Hemoglobin

Adults 26-34 picograms/cell

Macrocytic anemia Microcytic anemia Hyperlipidemia

RDWRed Cell Size Distribution Width

11.5-14.5 CV%(coefficients of variation)

Iron deficiency, vitamin B12 or folate deficiency, thalassemia

Posthemorrhagic anemia

Result not helpful unless anemia present

Platelet Adults140-400 x 103 /mm

Malignancy, myleogenous leukemia, polycythemia vera

Idiopathic thombocytopenic purpura, exposure to DDT, chemotherapy,

Count increases after exercise, in winter and at high altitudes

WBC Count Adults 5-103/l Infection, leukemia, malignant neoplasms

Viral infection, bone marrow depression or disorders

Age, time of day

Neutrophils 50-60% of total WBC count

Bacterial infection, inflammation, leukemia

Drugs, chemicals, radiation, blood diseases, and acute relentless bacterial infections with poor prognosis

Steroid administration, extreme heat or cold, age

Lymphocytes 20-40% of total leukocyte count

Leukemia, lymphoma, mononucleosis, viral disease

Chemotherapy, steroid administration, tumor, malignancy

Monocytes 2-6% of total leukocyte count

TB, subacute bacterial endocarditis, leprosy, lipid storage disease, some leukemias

Predisone use, hairy cell leukemia, RA, HIV

Eosinophils 1-4% of total leukocyte count

Allergies, parasite disease, skin disease, infections

Cushing’s syndrome, certain medications

Stress, time of day

Basophils 0.5-1% of total leukocyte count

Granulocytic and basophilic leukemia, myeloid metaplasia, Hodgkin’s disease

Acute infection, stress, steroid therapy

“Left Shift”

• Over 6% immature band neutrophils

• Typically indicates bacterial infection

• (“Right Shift” is hypersegmentation of neutrophils and = B12-Folate deficiency)

Physical Signs in Hematologic Disorders• Pallor

– Sclera and Buccal mucosae– Skin

• Pain– GI– Bone (pathological fractures / Arthralgias)

• Lymphadenopathy• Glossitis

– Tongue findings

• Fever

• Blood sugar dysregulation

• Liver dysfunction

• Hepato-splenomegaly– One or both organs

Physical Symptoms in Hematologic Disorders

• Fatigue

• Mental ‘fog’

• GI Pain / dysfunction

• Joint pain / Bone pain

• Immune changes

• Purpura

• Neurological tissue pain and dysfunction

• Weight loss

• Night sweats

• Blood sugar changes

• Pain:– Macrocytic Anemias– Leukemias– Sickle Cell Anemia– Multiple Myeloma

• Fatigue:– Microcytic and Macrocytic Anemias– Leukemias– Mono– Lymphomas

• Purpura:– Senile Purpura– ITP / TTP– True clotting disorders: VWF, Hemo.a&b

• GI Complaints:– Pernicious Anemia

• Lymphadenopathy:– Lymphomas– Mono

• Hepatomegaly / Splenomegaly:– Leukemias (both)– Mono (Spleen)

Basic Workup:

• Physical exam & Hx:– Signs of Pallor– Hx of Fatigue, Pain…

• Labs:– CBC, Differential, PLT– Reticulocyte count– Ferritin, TIBC

Follow up or basic additional testing:• Macrocytosis:

– MMA– Neutrophil segmentation– B-12 and Folate levels

• Microcytosis:– Iron studies– RBC morphology– Reticulocyte counts– Erythropoetin levels

• Lymphadenopathy:– WBC Morphology– EBV and CMV Virus studies– Bone marrow studies

• Hemolysis:– Indirect and Direct bilirubin– RBC morphology and membrane studies– Reticulocyte indices

• Pain:– Consider B12 anemias– Urine electrophoresis (Bence Jones Protein…)– R/O Hemolytic Anemias

• Neurological Sx:– First thought would be Macrocytic Anemia work up

Anemia

Overview of Anemia

Normal hematocrit (HCT) = 36% to 48%, hemoglobin (Hb) = 12 to 16 g/dl.

Anemia is defined as a low HCT and Hb.

Changes in intravascular volume can be reflected in the hematocrit.

Fluid overload leads to hemodilution and a lower HCT, whereas volume contraction can yield a spuriously elevated HCT even in the face of anemia.

Classification of Anemia Microcytic Hypochromic

Iron Deficiency

Thalassemia

Severe Protein Deficiency

Chronic Infection

Classification of Anemia

Normocytic Normochromic High Reticulocytes

Acute Blood Loss

Hemolytic Anemia

Low Reticulocytes Underproduction

Red Cell Aplasia

Drugs, Leukemia, Aplastic anemia

Chronic disease, liver or kidney disease

Microcytic Anemia

ThalassemiasDefect in the synthesis of either alpha or beta chains

Microcytic-hypochromicSmaller cells with higher hemoglobin than Fe deficient anemia

Form intraerythrocytic inclusions that damage RBC membrane and cause hemolysis

Microcytic Anemia

Beta-thalassemia minor

Caused by decreased synthesis of beta chains. One of two genes not present (heterozygous).

Microcytic Anemia

Beta-thalassemia major

Both genes for beta-chain synthesis defective or missing.

Begin at approximately 4 to 6 months of life.

Usually present with severe anemia

Pronounced wasting, jaundice, slow growth and development, and delayed onset of secondary sex features.

Macrocytic Anemia

Vitamin B12 deficiency May be Folic acid responsive

DiagnosisElevated MCV, low reticulocyte countHyper-segmented neutrophils

> 5 segments

Low vitamin B12 levelsLow methylmalonic acid (serum)

Hemolytic Anemia

Glucose-6-phosphate deficiencyMost common hemolytic anemiaMay see Bite Cells or Heinz Bodies on peripheral smearG6PD is Vital to RBC integrity

Glutathione reductase support in RBC is partially reliant on G6PD shunt

Offers selective advantage against malariaMalaria infests the RBC

Mediterranean ancestry more severe typeNot anemic unless exposed to oxidant drugs

Why we check RBC G6PD prior to high dose (> 5 gram) Vitamin C IV’s.

LDL Oxidation: The LDL has the potential to carry an incredible load of free radical.Anti-Oxidant effects of Vitamins E, C, GSH and the RBC - Lipid – Plasma Interaction

Reduced Glutathione

Oxidized Glutathione

Plasma

ASC

ASC RDHA

LDLRBC

TocoToco R

LDL + R = “oxidized LDL”

Hemolytic Anemia

Sickle CellInherited disease primarily in individuals of African ancestry

Replacement of glutamic acid by valine at position 6 of the chain – leading to hemoglobin S

Occlusion of precapillary aterioles

Anemia and splenomegaly

Attacks of pain in chest, abdomen and skeleton

Multiple infarctions in bone marrow

Hereditary Hemochromatosis

Inherited disorder that results from excessive iron absorption from foodGenerally manifests in those 40 to 60 years of age

Clinical Picture:

Liver failure (cirrhosis)Pancreatic failure (diabetes, specifically "bronze diabetes"

Clotting

CLOTTING PATHWAYS

Measured by: PTT

Drugs: Heparin

Measured by PT/INR

Drugs: Warfarin, ASA, Vitamin-E, EFA’s

Factors 2-7-9-10

PROTHROMBIN ACTIVATOR made up of V&X: Started by X alone and V becomes active with + feedback

Extrinsic Pathway: Damage outside of blood vessels.

Intrinsic Pathway:

Blood trauma (turbulence and viscosity) or collagen and blood contact.

Thrombolysis• Needed when the intrinsic clotting

mechanisms are activated– Arrhythmias– Fibrillation– Prosthetic valves– Hyper-coaguable (thick) blood

• High Fibrinogen• Dehydration

• Multiple sites in the clotting cascade can be affected

Anti-thrombotics

Outpatient

MOA Uses Adverse Effects

Other

Warfarin[Coumadin]

Vitamin K antagonist

(Extrinsic) Factors 2,7,9,10

Thrombosis, rheumatic heart disease, embolism, ischemic heart disease

Prolonged bleeding, hemorrhage, diarrhea, fever,rash

Monitor pro-thrombin time

Antithrombotics

Mainly IV / inpatient

MOA Uses Adverse Effects

Other

Heparin Inhibits clotting factors by binding to antithrombin III (AT3) and ENHANCING the thrombin blockade of AT3.

Prevention of deep vein thrombosis, embolism, DIC

Hemorrhage, cutaneous necrosis, chills, pruritus, fever

Administer cautiously in men-struating women, patients with liver disease or blood disease

Antithrombotics MOA Uses Adverse Effects

Clopidogrel[Plavix]

Aspirin (ASA)

Prevent formation of platelet aggregating substance: thromboxane A2 (TxA2) – The pro-inflammatory cytokine produced by COX activity along with PG2 in the arachadonate cascade.

Reduce risk of MI, Stroke

Salicylism (ASA), GI distress, bleeding, tinnitus, rash, occult blood

TTP(Plavix)

ASA for Prevention• Most patients use 75-162mg / day “low dose ASA”

– Average is one 81mg ASA (baby aspirin)

• Am J Cardiol 2008;102:396-400 compared the effects of aspirin 300 mg/day and combined therapy with aspirin 100 mg/day and clopidogrel 75 mg/day on platelet function – Both strategies significantly decreased ADP- and collagen-induced

platelet aggregation, the authors report: • 18 of 30 patients treated with aspirin 300 mg/day and • 25 of 30 treated with aspirin 100 mg/day and clopidogrel 75 mg/day had

adequate platelet inhibition.

• "Increasing the aspirin dose to 300 mg/day or adding clopidogrel to aspirin can provide adequate platelet inhibition in a significant number of those patients with impaired responses to low-dose aspirin," the investigators conclude.

Clopidogrel (Plavix) Rx:

• 75 mg Tablets

• Preventive: 75mg qd

• Acute (STMI): 300mg loading dose then 75mg qd

• Literature lists continuing ASA Rx as well

Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events.

N Engl J Med. 2006; 354(16):1706-17 (ISSN: 1533-4406)

• CONCLUSIONS: In this trial, there was a suggestion of benefit with clopidogrel treatment in patients with symptomatic atherothrombosis and a suggestion of harm in patients with multiple risk factors. Overall, clopidogrel plus aspirin was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes.

Vascular Hemorrhagic Disorders

• Purpura Simplex• The most common vascular bleeding disorder, manifested by increased

bruising and representing increased vascular fragility.

• Usually affects women. Bruises develop without known trauma on the thighs, buttocks, and upper arms.

• The history usually reveals no other abnormal bleeding, but easy bruising may be present in family members.

• The platelet count and tests of platelet function, blood coagulation, and fibrinolysis are normal.

• No drug prevents the bruising; the patient is often advised to avoid aspirin and aspirin-containing drugs, but there is no evidence that bruising is related to their use.

• The patient should be reassured that the condition is not serious.

Senile Purpura

Affects older patients

Present as dark purple ecchymoses

Usually confined to the extensor surfaces of the hands and forearms, persist for a long time

New lesions without trauma

No known treatment

No real danger

Henoch-Schönlein Purpura

Affects mostly childrenAn acute respiratory infection commonly precedes purpuraIs an inflammatory disorder of unknown cause characterized by IgA-dominant immune complexes in smaller venules, capillaries and arterioles

Usually causes a triad of symptoms, including:a purpuric rash on the lower extremitiesabdominal pain or renal involvement, andarthritis

Idiopathic Thrombocytopenia Purpura

Antibodies form against platelets

Frequently preceded by URI or other viral infection

Presents as petechiae and other bleeding such as CNS bleeding or bleeding gums

DiagnosisMay have antiplatelet antibodies (90% sensitive but only 25% specific)

Thrombotic Thrombocytopenic Purpura

Fatal disease. Lifespan to 30-40 years commonly

Due to inhibitor of vWF-cleaving protease and unchecked platelet aggregation

Criteria for diagnosis include:

Microangiopathic hemolytic anemia (schistocytes, helmet cells on smear)

Elevated LDH

Mental status changes or fluctuating focal neurologic deficits

Hemolytic Uremic Syndrome

Usually in infants, children, or pregnant or postpartum women

Hemolytic anemia with Kidney failure

EtiologyBacteria

In some cases, induced by a diarrheal illness caused by Escherichia coli O157:H7, Shigella, Staphylococcus, or other E. coli subtypes

DrugsSome cases are related to use of drugs (especially chemotherapeutic agents, tacrolimus, ticlopidine, oral contraceptives

Von Willebrand’s Disease

Most common hereditary coagulation disorder20 sub variants of this disease now known

Males and females are affected approximately equallyMany patients never diagnosed

Abnormal synthesis of von Willebrand factor (vWF) causing decreased platelet adhesion and decreased serum levels of factor VIII:C

History of heavy mensesEpistaxisEasy bruisingGastrointestinal bleeding are common

Disseminated Intravascular Coagulation

Occurs as a result of: Complications of obstetrics, including abruptio placentae, saline abortion, retained products of conception, amniotic fluid embolism, and eclampsia

Infection, especially gram negative with endotoxin release.

Malignancy, especially adenocarcinoma of pancreas and prostate, acute leukemia.

Elevated PT/INR or elevated PTTMimic Liver failure

Thrombocytopenia

Hemophilia A. Deficiency of factor VIIIX-linked recessive

Diagnose by factor VIII assay

PT and thrombin clot time are normal. PTT generally elevated but may be normal if >30% activity (mild disease)Treatment of factor VIII deficiency.

Minor cuts and abrasions, superficial ecchymosis, and nontraumatic hematuria may require no therapy. CNS trauma requires prophylactic therapy. Uncomplicated hemarthrosis, noncritical hematomas, and traumatic hematuria are treated with factor VIII to achieve a factor VIII level of 25% to 50% for at least 72 hours. Life-threatening hemorrhage and hematomas in critical locations require factor VIII to achieve a factor VIII level of >50% for 2 weeks.

Hemophilia B (Christmas disease) Deficiency of factor IX

X-linked recessive

Diagnose by factor IX assay

Treatment of factor IX deficiency.

Minimal bleeding can be treated with FFP.

Major hemorrhage is treated with prothrombin complex concentrate or FFP

Malignancy

Polycythemia

Relative / Reactive PolycythemiaReaction to increased erythropoietin

Renal arterial hypoxia, emphysema, tumors, tetralogy of Fallot

Also may have high WBC, platelets & RBC’s Later may have marrow fibrosis or acute myelogenous leukemia

Polycythemia VeraAbsolute increase in red cell mass

Fatigue, weakness, dizziness, headaches and visual problems

Itching after warm bath

Easy bruising or bleeding with little or no injury

Waldenstrom’s Macroglobulinemia

A malignant disease of B lymphocytes with overproduction of monoclonal macroglobulin

Increase IgM causes hyper viscous blood and peripheral vascular compromise.

Affects people over 50 years old

Overproduction of IgM causes a marked increase in the viscosity of the blood

5 in 100,000 express this disease

Multiple Myeloma

Characterized by neoplastic proliferation of single clone of plasma cell engaged in the production of a monoclonal immunoglobulin, usually monoclonal IgG or IgA

SymptomsBone and back pain; unexplained fracturesBleeding problems Aggravation of arrhythmias

• Signs and tests– Bence-Jones proteinuria– Hypercalcemia

– Bone marrow biopsy – Bone X-rays show fractures, hollowed out (“punched

out”) bone lesions

From the now out of print Saunders Review of Pathology, 1996.

Acute Lymphocytic Leukemia (ALL)80% of acute leukemia in childhood

(peak 3-5 years)

Present with fever, bone pain, hepatosplenomegaly

Associated with Down Syndrome, Radiation and Viral infections.

ALL: In children 3-6 month survival without treatment; treatment 90% complete remission

Acute Myeloblastic Leukemia:AKA: Acute Nonlymphocytic Leukemia

8 types

Most common leukemia in adults 15-39Often presents with Splenomegaly

May present with bleeding disorders

May present with high (>50,000) WBC

Auer rods in cytoplasm pathognomonic for AML

Poorly differentiated neoplasm, live 1 yr with chemotherapy, cure rate 10 – 15%.

The median age is about 45 yrMedian survival is 4 to 6 yearsIt is uncommon before 10 yr of age.

Well-differentiated granulocytic leukemiaMay include any cell line

Slow for 3 yrs then ‘blast crisis’ (accelerated phase) when 85% die.Signs and Symptoms

Hepatosplenomegaly FatigueGeneralized LAWeaknessAnorexia or weight loss95% of patients have a distinctive cytogenetic abnormality: The Philadelphia (Ph) chromosome

Chronic Myleogenous Leukemia (CML)

Chronic Lymphocytic Leukemia (CLL)

Most often affects adults over the age of 55Patients die from cytopenia secondary to bone marrow replacement or from infectionsMay be found incidentally on routine CBC

Increase in WBC count (> 15,000, but typically 50,000 – 250,000) A mature appearing lymphocyte that is morphologically no different than normal counterpart

SymptomsNoneEnlarged lymph nodes, liver, or spleen Fatigue Abnormal bruising (occurs late in the disease) Excessive sweating, night sweats Loss of appetite Unintentional weight loss

Hodgkin’s Lymphoma

20 YO - OR - 60 YO age predominance

Curable, familial, prognosis depends on stage

Symptoms:

A painless swelling in the lymph nodes in the neck, underarm, or groin. “Single / asymptomatic node, then spreads.”

Unexplained recurrent fevers “intermittent spiking fever”

Night sweats

Unexplained weight loss

Lymphocytopenia may occur early and become pronounced with advanced disease

Reed-Sternberg cell seen with Hodgkin's disease

Non-Hodgkin’s Lymphoma

Most common Lymphoma.More deadly than Hodgkin’s

prognosis based on grade

Associated with Burkitt’s and Immunoblastic Lymphomas.

Malignant monoclonal proliferation of lymphoid cells in sites of the immune system, including lymph nodes, bone marrow, spleen, liver, and GI tractNon-Hodgkin's lymphoma is a malignant (cancerous) growth of B or T cellsNHL occurs more often than Hodgkin's disease

Burkitt’s Lymphoma

• B-lymphocyte tumor – LA in the maxilla or mandible – Association with EBV infection in US– Associated with Malaria in Africa– May predispose patient to NHL