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Imaging sessionHaematology

MBChB V

Session 1MJ Coetzee

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Normal blood picture

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Normal blood smear

Normal red cells& platelets

Normal white cells

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Eosinophil

Basophil

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Normal band cell

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Normal bone marrow

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•Stem cells give rise toe cells that develop into mature cells in the circulation

•Problems with stem cells cause bone marrow failure and even leukaemia

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Normal bone marrow cells

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Normal bone marrow smear

Normal bone marrow particle (1/3 adipose cells)

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Hypercellular bone marrow

Particle on smear

Biopsy (histological picture)

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Hypocellular bone marrow

Adipose cells have replaced normal bone marrow

Bone

Aspirate particle

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Full blood count

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Full blood count-1• The FBC is a group of tests that

provides us with information about:– Red cells and their properties– Total white cell count and concentrations

of types of white cells (differential count)– Concentrations of platelets

• A blood smear is made and the morphology of the blood cells are reported

• Often the ESR is done simultaneously

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Full blood count -2

• Blood for a FBC is drawn into a purple tube, that contains the anticoagulant EDTA

• The tube should reach the lab. within 2 hours - otherwise artifacts can occur

• Manual blood counts entails involves pipetting by mouth and involves a risk of infection

• Automated cell counters count red cells, white cells & platelets, en does Hb and red cell indices

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Haemoglobin-1

• Normal Hb varies with age, sex & height above sea level

• In Bloemfontein (1300 m) the normal Hb for adults is:– Men: 14,5-18,5 g/dl

– Women: 12,5-16,5 g/dl

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Haemoglobin-2

• Hb can also be measured in g/l and mmol/l

• World Health Organisation– At sea level– Definitions of anaemia by experts

• Children < 10 j < 9 g/dl

• Adult men < 13 g/dl

• Adult women < 12 g/dl

• Pregnant women < 11 g/dl

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Red cell indices-1

• The Hb shows the presence/absence of anaemia

• The red cell indices show the type of anaemia

• The MCV (mean. corpuscular volume) is usually between 80-100 fl– MCV < 80 fl: microcytic– MCV 80-100 fl: normocytic– MCV > 100 fl: macrocytic

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Red cell indices-2• The haematocrit reflects the portion of

the blood that consists of RBCs.– It is used exstensively in the USA as an

indicator of anaemia, but not elsewhere

• The MCH (mean cell haemoglobin) reflects the amount Hb/RBC

• The MCHC gives an idea of the colour of the RBCs

• Nowadays the MCV is accurately measured and it is the most important

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FBC direct from the cell counter

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Haematocrit

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White cell count• The total WCC is 4,0-11,0 x 109/l• Most of the white cells are neutrophils• A leucopenia is mostly caused by a

decreased number of neutrophils, but not always

• A leucocytosis is mostly caused by an increased number of neutrophils, but not always

• Therefore it is important to know the absolute count of individual types white cells

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Report of the blood smear

• Although one can obtain a lot of information from the FBC, always read the comments on the blood morphology

• The morphology can give information about e.g. malaria, left shift, activated lymphocytes, etc, while most machines cannot do this– Comments put the counts in perspective

and lead one to determine the cause of an anaemia, etc.

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Red cell shapes

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Round macrocytosis(e.g. alcohol)

Oval macrocytes (e.g. megaloblastic anaemia

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Acanthocytes(e.g. liver disease)

Blood smear

Electron microscopy

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polychromasia, e.g. haemolysis

Rouleaux (e.g. TB, HIV)

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Spherocytes: blood smear

Shape of normal RBCs & spherocytes

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Target cells (e.g. liver disease)

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Common white cell disorders

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Neutrophils• Neutropenia

– Mostly caused by suppression– Also called agranulocytosis– Causes: antithyroid, anti-inflammatory drugs,

anticonvulsants, antipsychotics, cytostatics chemotherapy, radiation

– Effects: infections (esp. respiratory), opportunistic, fungi

• Neutrophilia (neutrophil leucocytosis)– Mostly caused by bacterial infections– With severe infections they can show toxic

granulation– A left shift indicates immature WBCs - infection

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Neutrophil leucocytosis

Toxic granulation

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Band cell (left shift)

Döhle bodies (infection)

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Leucoerythroblastic anaemia:White cell & red blood cell precursors

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Leucoerythroblastic anemia:bone marrow infiltrate by cancer cells

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Lymphocytes

• Lymphopenia– Mostly caused by drugs, e.g. steroids

• Lymphocytosis– Mostly caused by viral infections– With severe virus infections the lymphocytes

can appear activated

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The leucocyte in viral infection:reactive lymphocytes

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Monocytes & eosinophils

• Monocytosis– Mostly caused by chronic infections, e.g.

TB

• Eosinophilia– Parasitic infections, allergies, skin

conditions, neoplasia

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Storage artefact(blood that lies around)

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Other infections

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HIV

Acid-fast bacilli in bone marrow (TB)

Loose nuclear fragments

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MalariaThick

smears

Falciparum trophozoites

Falciparum gametocytes(longstanding

infection

Non-falciparum malaria (large

cells)

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Geographic distribution malaria - and haemoglobinopathies

2002

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Fe deficiency

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Pallor

“Strawberry” tongue:Fe deficiency

Hands useful, regardless of ethnicity

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Fe deficiency: spoon nails

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Hypochromic microcytic RBCs

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Normal (blue) Fe stain of marrow particle

No Fe stainin marrow particle

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Gastrointestinal bleed because of cancer(Ba contrast)

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Megaloblastic anaemia

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Oval macrocyte Megaloblastic BM

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Vit B12 deficiency: demyelinisation

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Haemolytic anaemias

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Jaundice of haemolysis

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Warm (IgG) AIHA:pherocytosis,

polychromasia, normoblasts

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Cold (IgM) autoimmune haemolytic anaemia: agglutination

Macroscopic agglutination in tube

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Mechanical haemolysis (schistocytes)

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• RBC cytoskeleton under phospholipid-membrane– Complex mutations

• Hereditary spherocytosis– Different mutations give

rise to loss of membrane (soccer ball RBCs)

• Rx: splenectomy

Causes inside the RBC membrane

Gall stones after chronic haemolysis (barium in gall bladder)

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• Enzyme deficiencies– G6PD deficiency common

in Africa

• Haemoglobinopathies– Thalassaemias, sickle Hb

• Infections– Malaria

• Falciparum

Causes inside the RBC

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Aplastic anaemia:purpura ofthrombocytopenia

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•Fanconi anaemia•Sister (L) is small,has abnormal thumbs,café-au-lait spots& an indwelling catheter forher regular trans-fusions•Sister (R) normal

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Platelets

• Thrombocytopenia– Decreased production (bone marrow

failure) or increased destruction (ITP)

• Thrombocytosis– Reactive: infections, post-splenectomy

– Thrombocytaemia: essential thrombocythaemia

64Describe the red cells please.

65What are these red cells called?

66What are the causes of this red cell phenomenon?

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What is the naem of this haemoglobinopathy?

68What is the single cause of all these red cell changes?

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Paper case 1• A. is a forty-five year-old lady that is

prematurely grey. She complains that she has become increasingly tired over the last few months. She can hardly walk around a block. She is also losing her balance. She is pale, slightly jaundiced and has cracks in the corners of her mouth. Her tongue is raw and her pulse is fast. She has lost her sense of vibration in her arms and legs. She has a white cell count of 2.5 x 109/l (normal 4-11 x 109/l), haemoglobin of 6 g/dl (normal 12.5-16.5 g/dl) and platelets of 100 x 109/l (normal 150-400 x 109/l). Her red cells are oval and macrocytic. The nuclei of her neutrophils are hypersegmented.

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• Paper case 2

• N. is a 50-year old man that presents with exercise intolerance. He eats a balanced diet. He had a partial gastrectomy for a bleeding ulcer, five years ago. His full blood count shows: white cells 4 x 109/l, haemoglobin 9 g/dl and platelets 100 x 109/l. The rapport says that he has oval macrocytes.

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Paper case 3• Ms H. is 30 years old. She has three

children and is pregnant. Her husband lost his job recently and they live in Joe Slovo informal settlement. She feels increasingly tired and presented at the Polyclinic. She becomes unsteady and complains that her heart beats fast. She has developed a taste for clay.

• She is pale and has slight ankle oedema. Her pulse is 90/min. She is 30 weeks pregnant. Her haemoglobin is 8 g/dl with a mean cell volume (MCV) of 65 fl.

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Paper case 4T. is an 18-year old woman that has become increasingly pale and tired over the last fortnight. Her eyes are yellow. Her left upper abdomen is tender. Her mother had a similar condition as a youngster and had a splenectomy. After the operation her mother’s symptoms never recurred. T’s FBC shows the following: WBCs 7 x 109/l, haemoglobin 8 g/dl and platelets 250 x 109/l. Her blood smear shows spherocytes and her reticulocyte count is raised.