Introduction to Haematology Haematology The study of blood forming tissues and circulating blood components.

. Functions of Blood: 1) Deliver nutrients, oxygen and hormones to tissues 2) Collect aste from cellular metabolism !) Deliver cells to tissues for protection against the external environment ") To prevent lea#age by closing holes in blood vessels Circulating blood accounts for $%&' of total body eight and is composed of cellular and fluid elements. Cellular elements: (ed blood cells )hite blood cells *latelets Fluid elements: *lasma vs. serum )ater +lectrolytes *roteins e.g. clotting factors, antibodies and transport proteins Diagnosis of haematological disorders: History ith emphasis on bleeding, infections and constitutional symptoms +xposure to toxins or chemicals (evie of systems ,amily history Physical examination s#in, mucosae, eyes, organomegaly, lymphadenopathy, bony tenderness. Peripheral blood measurements -anual vs. automated Specimen collection .lood is collected in tubes that contain anticoagulant%+DT/, Trisodium citrate and heparin (atio of blood to anticoagulant must be appropriate .lood can be stored for testing at a later time BUT storage conditions must be appropriate (e0uest forms must be accurately and completely filled out Cell counts -anual % -ay be imprecise and technically time consuming

/utomated Changes in impedance in electrical flo Differences in light scatter properties 1ther information obtained 2aematocrit 2aemoglobin concentration -ean corpuscular volume -ean corpuscular haemoglobin concentration -ean corpuscular haemoglobin (ed cell distribution idth hite blood cell counts -ay be inaccurate by automated methods because of aggregated platelets, nucleated red cells, incomplete lysis of red cells, ).C agglutination !eucocyte differentials /utomated methods tend to be more accurate because many more cells are counted than by manual methods BUT all abnormal cells cannot be identified by the machines. ,lagging the result ould indicate abnormalities that are present ithout characteri3ing specific abnormality. Platelet analysis /utomated methods more reliable than manual methods. +rrors may occur in the presence of platelet clumps or red cell fragments. Morphology of blood cells 4lides prepared from anticoagulated blood 5ncoagulated blood prepared from fingerstic# procedure can also be used .lood is smeared on a glass slide usually 4lide is stained using )right or -ay%6run ald%6iemsa stain 4mear is then examined at 17 to 27x ob8ective 4mear is first scanned before going on to higher po er for ).C differentials (.C should be assessed for si3e, shape, haemoglobin distribution and presence of inclusions /ssess (.C morphology in an area here the cells are 8ust touching but do not overlap 9ormal red cells are round ith a central area of pallor /nisocytosis variation in si3e *oi#ilocytosis variation shape 2ypochromia *oor haemoglobinisation 4pherocytes :ac# central area of pallor -acrocytes Cells are larger than normal -icrocytes Cells are smaller than normal Platelet numbers and morphology are assessed White blood cells :eucocyte morphology and distribution should be assessed. /t least 177 hite cells should be counted for manual differential count. )hite blood cells include neutrophils, eosinophils, basophils, monocytes and lymphocytes.

;mmature ).C include bands, metamyelocytes, myelocytes, promyelocytes and blasts. .one marro examination Cytology prepared from bone marro aspirate Cellularity and infiltration assessed from bone marro biopsy Indications for bone marrow assessment +valuation of primary bone marro tumors 4taging of tumors /ssessment of abnormalities seen on the peripheral blood smear /ssessment of infectious disease processes +valuation of metabolic storage diseases Sites for bone marrow evaluation /nterio%medial tibia in children 4ternum /nterior and posterior iliac crest Staining of bone marrow )right or -ay%6run ald%6iemsa stain 2aematoxylin and eosin for biopsy 4pecial stains Cytochemical stains ;mmunohistochemical stains Cytogenetics Erythrocyte sedimentation rate +4( commonly done but nonspecific (eflects the tendency of blood to settle more rapidly in some disease states ;ncrease in rate is related to increases in plasma fibrinogen, immunoglobulins and other acute phase reactive proteins (ed cell shape and numbers may also affect rate of fall ;ncreases ith age in other ise healthy people *oor screening test in asymptomatic individuals 5seful in follo ing the course of disease e.g. (./., 2odg#in<s -easured using )estergren or )introbe method 5nits are mm=hr

"#"$%I" Definition /naemia is a disorder in hich the patient suffers from tissue hypoxia due to a reduction in the oxygen%carrying capacity of the blood. The underlying problem is a decreased red cell mass, but it is demonstrated in clinical practice by a reduction in the haemoglobin concentration or red cell count belo the lo er limit of normal for the age and gender of the patient. /naemia is a sign of an underlying pathology >it is not a diagnosis) hose recognition re0uires an approach to the hole patient for the delineation of the mechanism and causes>s) of the red cell deficit. #ormal &alues ;n order to identify the anaemic state one needs to have #no ledge of the normal haematological values. Red cell count -en )omen ;nfants >full%term, cord blood) Children, 1 year Children, 17%12 years Haemoglobin -en )omen ;nfants >full%term, cord blood) Children, 1year Children, 17%12 years Pac ed cell volume !PC"# haematocrit$ -en )omen ;nfants >full%term, cord blood) Children, ! months Children, 17%12 years
$.$ ".? $.7 "." ".& 1.7 x 1712=l 1.7 x 1712=l 1.7 x 1712=l 7.? x 1712=l 7.& x 1712=l

1$.$ 2.$ g=dl 1".7 2.$ g=dl 1@.$ !.7 g=dl 12.7 1.7 g=dl 1!.7 1.$ g=dl

7."& 7.7& >l=l) 7."2 7.7$ >l=l) 7.$" 7.17 >l=l) 7.!? 7.7@ >l=l) 7."1 7.7" >l=l)

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Classification There are t o main classifications of anaemiaA 1) the pathogenetic and aetiological classification, based on the cause of the anaemiaB 2) the morphological classification based on the characteristics of the red cell. These t o classifications are complimentary to each other, as the clinical investigation of a patient ith anaemia involves t o distinct stepsA 1) determination of the morphological type of anaemia and 2) determination of the cause of the anaemia. The aetiological classification of anaemia can be further subdivided into either >a) hypo%regenerative or >b) hyper%regenerative. The presence of anaemia may result from the failure of bone marro production of red cells >hypo%regenerative) or increase in red cell destruction or consumption ith a concomitant increase in red cell production >hyper%regenerative). 'eticulocytes +ach day approximately 7.?' of the red cell pool needs be replaced by young erythrocytes released from the marro . (eticulocytes are larger than mature red cells and contain portions of polyribosomal (9/ material. 4upravital stains of peripheral blood detect these reticulated cells, and their number permits an assessment of the marro <s response to the peripheral anaemia. The reticulocyte count provides an easy means of implicating either the marro or the periphery as the source of the anaemia. This differentiation dictates the further investigative or#up by narro ing the focus to the bone marro in reticulocytopenic states but to peripheral loss=or haemolytic abnormalities hen reticulocytosis is present. 9... /naemia C :o reticulocyte count D 2ypo%regenerative anaemia /naemia C 2igh reticulocyte count D 2yper%regenerative anaemia (eticulocyte Count

This is usually expressed as a percentage of the red cells examined in an

individual patient. The normal count is as follo sA /dults and children 7.2%2.7' ;nfants >full%term, cord blood) 2%@'

Theoretically, the reticulocyte percentage can increase because

1) more reticulocytes or 2) fe er mature red cells are present in the circulation.

(ed Cell *roduction The ma8or factor controlling the rate of red cell production is the oxygen content of the arterial bloodB a decrease in oxygen content stimulates erythropoiesis hile an increase depresses it. The red cell mass is maintained ithin the prescribed limits through the regulatory feedbac# stimulus of the humoral factor erythropoietin. )hen the cause of anaemia is blood loss or haemolytic destruction in the peripheral blood, erythropoietin overdrive of the marro leads to reticulocytosis. (eticulocytes released under heavy erythropoeitin stimulation remain in the peripheral blood longer than the usual one%day maturation time of Enonstress reticulocytes<. The reticulocyte index ('I) corrects for 1) the prolonged maturation time of the reticulocytes and 2) the anaemia. 'I D (eticulocyte count >') x *atient *CF >1=1) x 1 9ormal *CF >1=1) -aturation time >days) The maturation of reticulocytes in the circulation isA 1.7 day hen the *CF is 7."$ l=l, 1.$ days hen the *CF is 7.!$ l=l, 2.7 days hen the *CF is 7.2$ 1=1, 2.$ days hen the *CF is 7.1$ l=l. e.g. reticulocyte count D 27' *CF >patient) D 7.2$ l=l *CF >normal) D 7."$ l=l -aturation time D 2.7 days +, x ,-+. * .-. +-, ,-/.

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(; G2 2ypo%regenerative anaemia (; H! 2yper%regenerative anaemia

%orphological Classification /n alternative classification of anaemia is based on the morphology of the red cells, usually their si3e and staining characteristics. (ed cells may be normal in si3e >normocytic), large >macrocytic), or small >microcytic).

They stain pin# ith the stains used in haematology, but there is a central area of pallor hich does not exceed 1=! the diameter of the cell. Cells stained in this ay are normochromic. ;f the central area of pallor is greater than 1=! the diameter of the cell it is described as hypochromic. 1n this basis the anaemia may be classified as 1) hypochromic=microcytic, 2) normochromic=normocytic, or !) macrocytic. The si3e and staining characteristics of the cells may be ob8ectively measured by the mean corpuscular volume >-CF), mean corpuscular haemoglobin >-C2), and mean corpuscular haemoglobin concentration >-C2C). -CF >fl) D -C2 >pg) D -C2C >g=dl) D *CF >l=l) x 1777 (CC >1712=l) 2aemoglobin >g=dl) x 17 (CC >1712=l) 2aemoglobin >g=dl) *CF >l=l)

#ormal 0alues Mean cell volume !MC"$ /dults ;nfants >full%term, cord blood) Children, 1 year Children, 17%12 years Mean cell haemoglobin !MCH$ /dults Mean cell haemoglobin concentration !MCHC$ /dults and children
?$ ?fl 17@ fl >mean) &? ? fl ?" & fl

2I.$ 2.$ pg

!! 2 g=dl

Calculating the absolute values and blood film examination are both important in the assessment of the anaemic patient. Clinical Features The symptoms and signs in an anaemic patient are due toA 1) the anaemia itself 2) the disorder causing the anaemia

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The haemoglobin level at hich symptoms of anaemia develop depends on t o main factorsA 1) The rate of development of the anaemia 4ymptoms occur at a higher haemoglobin level ith rapidly developing anaemia e.g. acute haemorrhage, than in a slo ly developing chronic anaemia. 2) The age of the patient Children and young adults can tolerate a much greater degree of chronic anaemia than older patients due to cardiovascular compromise ith advancing age. 4ymptoms and signs >a) >b) Tiredness, easy fatigability and generali3ed muscle common and often the earliest symptoms of anaemia. ea#ness are the most

*allor *allor C icterus D hemolytic anaemia. :emon yello pallor D pernicious anaemia. )axy dead hiteness C cold and moist palms D acute blood loss. Cardio%pulmonary i. Dyspnoea >on exertion or at rest in severe cases), shortness of breath and palpitations are common symptoms in most patients. ii. iii. /ngina is not uncommon in older patients due to myocardial ischemia. -ost patients ith angina usually have pre%existing coronary stenosis. -urmurs ,lo murmurs may occur. These are soft, systolic murmurs heard at the pulmonic area or apex reflecting increased blood flo and turbulence. Congestive cardiac failure is not uncommon in severe anaemia. The heart fails because the anoxic myocardium is unable to cope ith the extra or# resulting from the increase in cardiac output. The signs are usually those of congestive heart failure pulmonary congestion, raised 8ugular venous pressure, hepatomegaly and peripheral oedema.

>c)

iv.

>d)

9euromuscular 2eadache, vertigo, tinnitus, faintness, lac# of mental concentration, dro siness, restlessness and muscular ea#ness are common symptoms of severe anaemia. 4ome of these signs may be manifestations of cerebral hypoxia.

*aresthesias and neurological deficits are common in pernicious anaemia. >e) /limentary 4ystem 6astrointestinal symptoms are fre0uent in anaemic patients. 4ome are manifestations of the disorder underlying the anaemia e.g. duodenal ulcersB others may be a conse0uence of the anaemic condition hatever the cause. 6lossitis and atrophy of the papillae of the tongue commonly occur in nutritional anaemia. ,ever )hen anaemia is severe, fever of mild degree may occur other than the anaemia. Compensatory Physiological "d1ustments to "naemia The main function of haemoglobin is to transport oxygen from the lungs to the tissues. /naemia reduces the oxygen%carrying capacity of the blood and results in tissue hypoxia. This hypoxia causes dysfunction of the blood<s tissues. The symptoms and signs of anaemia are, therefore related to many systems especially those ith high oxygen re0uirements such as the musculos#eletal system, the cardiovascular system and the central nervous system. ,ollo ing the reduction in the oxygen carrying capacity of the blood the body brings into play the most effective use of the available haemoglobin. These occur first in the red cell itself and secondly in the circulation. 1. (ed cell The primary function of the red cell is to transport oxygen from the lungs to the tissues in ade0uate 0uantities and at a sufficient partial pressure to permit rapid diffusion from the blood. The oxygen%dissociation curve is constructed by plotting values of percent saturation of blood ith oxygen against those of partial pressure. The curve is sigmoid in shape. ithout cause,

>f)

The 2xygen3Dissociation Cur&e

 ;ncreasing or decreasing oxygen affinity is associated

ith shifts of the oxygen%dissociation curve to the left or right respectively. The partial pressure of oxygen hen its saturation is $7' is 2& mm2g.

The binding and release of oxygen by haemoglobin are profoundly affected by the variations in the concentration of phosphates, especially 2,! diphosphoglyceric acid >2,!D*6). /n increase in red cell levels of 2,! D*6 is found in chronic anaemia. This increase facilitates the delivery of oxygen to the tissues by reducing the affinity of haemoglobin for oxygen at the oxygen tensions found in capillaries. The oxygen% dissociation curve is then shifted to the right. 2) Circulation Cardiac compensation includes an increase in cardiac output and in the rate of circulation of the blood. This is brought about mainly by an increase in the stro#e volume of the heart but to a lesser extent by an increase in the heart rate. )hen the haemoglobin falls belo & g=dl the cardiac output is usually increased, hen it is less than $g=dl an increase in stro#e volume and to a lesser extent in heart rate especially ith exercise. The total blood volume is #ept normal by the expansion of the plasma volume, in order to maintain an ade0uate circulation. There is redistribution of blood flo a ay from tissues having lesser oxygen re0uirements to those ith greater oxygen re0uirement. Thus s#in flo is decreased hile cerebral and muscle flo are increased.

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The compensatory mechanisms commonly allo the patient to remain asymptomatic at rest but exertion may produce symptoms as a result of the increased oxygen re0uirements. %anagement ;n the investigation of the patient suspected of being anaemic three 0uestions must be ans ered. 1) ;s the patient anaemicJ 2) )hat is the type of anaemiaJ !) )hat is the cause of the anaemiaJ The principles of management of the anaemic patient areA 1) treatment of the disorder causing the anaemia and 2) treatment of the anaemia.

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