BENIGN DISORDERS OF WBC

Definitions
o Leukopenia = WBC
o Leukocytosis = WBC
Neutrophil maturation
o Myeloblast promyelocyte myelocyte metamyelocyte
Band Neutrophil
Neutrophil precursors
o Myeloblasts seen in BM
o No seen in peripheral blood if so = AML
o CD34, CD117
Neutrophils
o Reserve pool in BM
o M:E in BM = 2:1 to 4:1
o In blood
Circulating pool (in CBC)
Marginating pool (not in CBC)
Neutropenia
o Causes
Congenital
Kastmanns = Body cant make PMN
Myelokathexis = PMN cant leave BM
Acquired
Infections (bacteria), drug, toxins, autoimmune etc
o Clinical
Infection mouth/throat ulcer
Septicemia S. epiderm. in bowel
Neutrophilic Leukocytosis
o Causes
Bacteria
Inflamm/tissue necrosis myositis/vasculitis
Any time stress hormone released
Asplenia in last few days
Granulocyte leukocytosis
o Leukemoid Reaction
Mimics leukemia
Reactive leukocytosis
PMNs and immature PMNs (1st 3) in blood
Should not be in blood = Left Shift
Cause = bacterial inf / hemolysis
o Leukoerythroblastic Reaction
Nucleated RBC + Left shift
Myelofibrosis
Defects of PMN Fxn
o In chemotaxis
Lazy leukocyte syndrome
Corticosteroid therapy = keeps PMNs in BV
Myelodysplasia = PMN die in BM
o In phagocytosis
o In killing
Chronic granulomatous disease
Abnormal oxidative metab
Recurring infections in early child
Myeloperoxidase defi
Chediak-Higashi syndrome
Abnormal White blood cells
o Neutrophilic toxic exchange = vacuoles/ongoing infections
o Dohle body = sign of ongoing infection
o Hypersegmented PMN = megaloblastic anemia
o May-Hegglin anomaly = Giant platelets

o Pelger-Huet anomaly = myelodysplastic syndrome

o Chediak-Higashi syndrome = giant granules in monocyte/PMN
o Alders anomaly = same but smaller granules in all cell types
Monocytosis
o Chronic bacterial infections TB/viral/fungi
o Hairy Cell Leukemia = pathognomonic to monocytosis
Eosinophilic Leukocytosis
o Allergic disease
o Parasitic diseases
o Hypereosinophilic syndrome = if for 6 mo and not due to above 2
o Chronic eosinophilic leukemia = Clonal
Basophil Leukocytosis
o Chronic Myeloid Leukemia (CML)
Langerhans Cells
o Dendritic cells that present antigens to nave T cells
o In skin and mucosa
o Tennis racquet Birbeck granules
o Neoplastic prolif = Langerhans cell histiocytosis
o CD1a and S-100
Langerhans cell histiocytosis
o Malignant prolif of Langerhans
o Letterer-Siwe disease = multiple areas
o Eosinophilic granuloma = w/ eosinophils
o Hand-Schuller-Christian disease = Focal
Hemophagocytic Lymphohistiocytosis
o histiocytes in BM (Macs in BM = histiocytes)
o Caused by infection
o Fever, pancytopenia (b/c cells phag by macs), multiorgan fail,
coagulopathy, CNS signs
Sinus Histiocytosis w/ massive lymphadenopathy
o Less fatal than previous one
o Lymph nodes w/ histiocytes that have lymphocytes inside their
cytoplasm but not eating them
o Rosai-Dorfman disease
o Painless, chronic cervical lymphadenopathy
Lysosomal Storage Diseases
o Gauchers Disease Auto Rec
Accum of glucosylceramide in lysosomes of RES cells
(liver/BM)
Def of glucocerebrosidase
3 types baed on onset age
Chronic = adult / Acute infantile neuronopathic / Mixed
Assoc w/ Parkinsons disease, multiple myeloma
Anemia, leukopenia, thrombocytopenia
Dx via assay of white cell glucocerebrosidease and DNA analy.
o Niemann-Pick
Sphingomyleinase def
Accum of sphingomyelin and cholesterol
Most are infants that die in 1st few years of life
Hepatosplenomegaly w/ lung and cns involvement
Cherry-Red spot in retina
Pancytopenia
Foam Cells in BM aspirate

MYELOPROLIFERATIVE NEOPLASMS
Clonal prolif of hematopoietic marrow stem cells
o Hypercellular marrow
o PMNs, RBC, or platelets
o Hepatosplenomegaly marrow fibrosis or acute leukemia
o All result from acquired genetic abnormality in the stem cell
PV/ET/MF
o All 3 have mutation of tyrosine kinase JAK2
o JAK2 is needed for normal myeloid devel.
Polycythemia Vera
o Myeloid clonal prolif RBC mass (Hb)
o WBC may also occur
o Symptoms
Symptoms due to viscosity
Headache/dizziness/visual disturbances
Facial plethora/erythromelalgia (burning pain in hands/feet)
Thrombosis or bleeding
Pruritus after warm shower
o Labs
Normocytic RBCs
BM hypercell w/ erythroid and megakaryocytic hyperplasia
JAK2 mutation
o WHO criteria = 2 major + 1 minor or 1 major +2 minor
Major = Hb and JAK2 mutation
Minor = EPO, BM findings above
o Other causes need to be ruled out
EPO, chronic hypoxemia (smoker), high altitude, dehydration
o Tx = phlebotomy/hydroxyurea/ASA
o Can become = Primary myelofibrosis/Acute Myeloid Leukemia
Essential Thrombocytosis/thrombocythemia
o Presence of chronic non reactive thrombocythemic state not due to
one of the other MPNs
o Dx based on exclusion of other diseases
platelets
Megakaryocytic hyperplasia in BM
No Philadelphia chromosome
No causes for reactive thrombocytosis
Absence of myodysplastic syndrome/Primary myelofibrosis
o Symptoms
Vasomotor symptoms = light headed, syncope
Unusual thrombotic event/bleedings
o Labs
High platelet # in peripheral blood
Enlarged mature megakaryocytes in BM
JAK2 mutation
o Tx = hydroxyurea/ASA
o Can become = Primary myelofibrosis
Primary myelofibrosis
o Myeloid stem cell clonal prolif w/ reactive fibrosis of BM
o Marrow fibrosis due to abnormal megakaryocytes that secrete
cytokines that stim fibroblasts/fibrosis
o Extramedulary hemat = hepatosplenomegaly
o Signs

o
o
o

Fatigue
Splenomegaly = abd pain + weight loss
Symptoms of hypermetab state, fever, bone pain, night sweats
Labs
Smear = Tear drop cells
BM reticulin stain shows fibrosis
JAK2 mutation
Tx = supportive care/hypomethylating
Cure stem cell transplant
Can become = acute myeloid leukemia

Chronic myeloid leukemia

o Most common MPN
o Uncontrolled production of PMNs/Basophils/Eosinophils
o W/o Tx triphasic course
Chronic phase accelerated phase terminal blast crisis
Terminal blast resembles acute leukemias = AML(2/3) and
ALL(1/3)
o Signs
Asymptomatic - discovered when pt in for routine check
Fatigue, malaise, weightloss, abd full, splenomegaly
o Labs
Leukocytosis
Lots of immature cells in peripheral blood
Anemia and platelets
BM = very hypercellular
Philadelphia chromosome (22)
T9;22
Fusion of BCR (22) and ABL1 (9) = BCR-ABL1 =
unregulated tyrosine kinase (210kD)
o Tx =Tyrosine Kinase inhibitors - blocks binding of ATP to protein
Mastocytosis
o Mast cell accum due to clonal disorder (KIT mutation)
o Cutaneous mastocytosis = only in skin
o Systemic mastocytosis = infiltrate multiple extra-cutanous organs
o Signs
Symptoms related to prostaglandin and histamine release
Flushing, pruritus, abd pain, bronchospasm
o Can become = acute leukemia
Chronic myelomonocytic Leukemia
o Features of myeloprolif neoplasm and myelodysplastic syndrome
o Peripheral blood monocytosis + BM dysplasia
Anemia, thrombocytopenia, cytopenia and hepatosplenomegaly
o Labs
BM hypercellular w/ <20% blasts
No BCR-ABL
o Becomes = AML aka poor prognosis
o Cure = stem cell transplant
Juvenile Myelomonocytic leukemia
o In first 4 years of life in
o Children w/ Noonans syndrome and Neurofibromatosis = risk
o Features of both MDS/MPN
o Myelomonocytic prolif in BM/blood
o Hepatosplenomegaly/lymphadenopathy due to leukemic
infiltration of organs
o No Philadelphia chromosome
o Cure = stem cell transplant

o Refractory anemia w/ excess blasts

o MDS w/ isolated del(5q)
Differential Dx mimic morph of MDS
o Vit B12 and folic acid def
o Heavy metal tox
o Viral infection
o Copper def
o Zinc excess
Prognosis
o Based on degree of cytopenias/ % blasts in BM, and cytogenetic
abnormalities
o High risk pts progress to cytopenias and/or acute leukemia
Treatment depends on prognosis
o Low risk = transfusion growth factors
o High risk = hypomethylating agent + stem cell transplant
MYELODYSPLASTIC SYNDROMES
MDS = heterogeneous group of clonal disorder of marrow stem cells
Features
o Dysplastic features
APLASTIC ANEMIA
o Progs to AML possibly
Definition = diminished or absent hemat precursors in BM due to
o Ineffective blood cell production leading to BM failure
injury to stem cell. Name is misnomer b/c all cell lines affected w/
BM has prolif but apoptosis = hypercell marrow but
pancytopenia
cytopenia

Causes
o De novo = primary
o Congenital
o Others = therapy related MDS/tMDS/secondary MDS
Fanconis anemia auto rec
o > 65 Years old and Male, risk w/ age
Defect in DNA repair enzyme / chromosomal breakage
Causes
Skeletal, renal, growth abnormal
o DNA damage to stem cell
Prog to MDS or AML
o Environ factors benzene, radiation, tobacco, chemo

Dyskeratosis congenital sex linked

o Inherited abnormal trisomy 21, fanconi anemia, bloom
syndrome, ataxia telangiectasia, PNH, congenital neutropenia
Nail/skin atrophy
Symptoms
Disorder in enzymes involved w/ telomere length
o RBC, platelets, mature granulocytes (PMN, eos, baso, mast)
o Acquired
o Anemia/fatigue
Idiopathic
o Neutropenia-infection/thrombocytopenia-bleeding
Drug induced
Labs
NSAIDS phenylbutazone, chloramphenicol
o Anemia + low reticulocyte response
Gold, solfonamides, antiepileptics, nifedipine
MCV = macrocytic or normal
Viruses = Parvovirus, HIV, EBC
o Leukopenia = WBCs
Patho
o Thrombocytopenia = early manifest if del(20q)
o Damage induced by above lymphocyte activation
o Smear
o Unregulated lymphocyte activation of Cytotoxic T cells
RBC = normocytic or macrocytic
directed against stem cells
WBC = dysplastic PMN
Lab manifestations
Size change, abnormal lobation, abnormal granularity
o Symptoms due to progressive cytopenias
Pseudo-Pelger-Huet abnormality
Fatigue/hemorrhage/menstrual flow/petechial gum bleeding
o BM = normal/hypercellular
o Hypocellular BM = lots of fat in BM
o Ringed sideroblasts
o Megakaryocytes large mononuclear forms
Paroxysmal Nocturnal hemoglobinuria
hypogranular/multiple small lobes disconnected
o Related to aplastic anemia
o Granulocyte dysplasia hypogranular/hyposegmented
o Signs
o Nucleus blebbing/multinucleation
Hemolytic anemia/jaundice/pink-red urine
o Howell Jolly bodies and Basophilic stippling
Hypercoagulable state = due to free Hb, platelet activation and
Diagnosis
BM failure
o Requires BM biopsy/aspiration
o Patho
o >10% of affected cells
Mutation of PIG-A gene that makes GPI anchors in
o Blast cells needs to be <20%
platelets/WBC/RBCs
Loss of GPI
WHO classification
o Refractory cytopenia w/ unilineage dysplasia
loss of decay accelerating factor (DAF) (CD55)
o Refractory anemia w/ ring sideroblasts (only erythroids)
loss of membrane inhibitor of reactive lysis (CD59)
o Refractory cytopenia w/ multilineage dysplasia
Both are complement regulatory proteins

 Leads to complement med lysis of RBCs (hemolysis) and

activation of platelets (thrombosis)
During sleep Resp Acidosis intravasc hemolysis
hemoglobinemia/hemoglobinuria
o Tx
Immunosuppression to reverse marrow failure
Stem cell transplant

Sudan Black
Non-specific esterase monocytes/myeloblasts
o Immunophenotyping = Flow cytometry
Myloid markers = CD13, CD33
Immature markers = CD34, CD117
o Cytogenetics/FISH
Abnormal karyotypes in the pts
Karyotype on dividing metaphase cels
FISH done on non-dividing cells
o Molecular markers
NPM, FLT3, CEBPA
Aids in prognosis
WHO Classification
o Dx requires only cytogenetic abnormality (no need for >20%
blasts) in following 3 = all good prog
T8;21 RUNX1
Core binding factor (CBF) needed for normal hematop.
Translocation chimeric protein / disrupted
T15;17 PML-RAR
Inv(16) involves CBF
o AML-MDS related features = poor prog
AML that came from previous MDS
o Therapy related AML/MDS = Poor
ACUTE LEUKEMIA
AML in pt w/ hx of cytotoxic therapy
Ex) pts txd for breast/ovarian/hodgkins have small chance of
Transformed cell from myeloid stem cell Acute myeloid leukemia
developing AML
Transformed cell from lymphoid stem cell Acute lymphoblastic L
Acute Myeloid Leukemia
Definition
o Clonal prolif of myeloid precursors accum of leukemic blasts
in BM and other tissues.
o Inhibition of normal RBC/platelet/granulocyte production
Most common acute leukemia in adults
Assoc w/ env/chemicals/radiation/chemo/genetics (trisomy 21
downs) and others
Signs
o Anemia/fatigue
o Neutropenia/infections
o Thrombocytopenia/bleeding/ecchymosis/epistaxis/menorrhagia
o Fever/bone pain
o Unusual Signs
Myeloid sarcoma = small tumors of leukemia cells/extramed
Leukemia Cutis
Gingival hypertrophy = tissue infil seen w/ monocytic types
Coagulation abnormalities Acute promyleocytic leukemia
(APL) T15;17
Labs
o Normocytic anemia
o Platelet
o WBC low/high/abnormal
o Blasts
Immature cells/large nuclei
Prominent nucleoli
Fine granular chromatin
Auer Rods = Pathognomonic
Dx
o Marrow infil w/ >20% blasts (if <20% possibly MDS)
o Monotonous cell population clonality
o Stains = to diff from lymphoid precursors
Myeloperoxidase

o AML not otherwise specified = classified by morphology

M5 = Acute monoblastic/monocytic leukemia
monoblasts in circulation
Tissue invasion/gum hypertrophy
CD11c, CD14 + for NSE
M6 = Acute erythroid leukemia
M7 = Acute Megakaryoblastic leukemia
BM w/ fibrosis and cells show pseudopod formation
In pts w/ Downs syndrome
Megakaroblasts = CD41, CD61
AML unique feature = Acute promyelocytic leukemia (M3) T15;17
o Retinoic acid receptor alpha (RARa) on 17
o PML gene on 15
o PML-RARa fusion blocks normal differentiation by retinoic
acid
Multiple granules and multiple Auer Rods
mortality due to coagulopathy (DIC)
o Tx diff from other leukemia
Trans-retinoic acid + Arsenic
Prognosis based on cytogenetics
Tx
o Fit pts = Good risk
Induction initial chemo 7+3 Ara-C and anthracycline
Consolidation = 3-4 cycles of Ara-C
In T15;17 use Atra/Arsenic
o Fit/High risk pt = Bone marrow transplant
o Not fit
Supportive care
Hypomethylating agents

 Pathognomonic of CML
Protein in ALL is 190 kD unregulated tyrosine kinase
T12;21
Hyperdiploidy good prognosis
Hypodiploidy Poor prognosis
Examples
o ALL B cell leukemia
Need flow and cytogenetics
Flow CD10, CD19, TdT+, Myloperox/Sud black Negative, PAS
positivity
Cytogenetics T9;22
o Burkitts lymphoma/leukemia overlap disease
Abnormal c-Myc oncogene on chromosome 8 to
T2;8
T8;14
T8;22
Round/multiple nuclei and cytoplasmic vacuoles starry sky
o T cell
More common in adolescent
Present w/ mediastinal mass
Heptosplenomegaly, lymphadenopathy
Nuclear folds
CD2, CD3, CD7, TdT
Treatment
o Regiments directed against lymphoblasts
o Induction, Consolidation, Maintenance, CNS prophylaxis, Stem
cell transplant
Acute Lymphoblastic Leukemia
Definition
o Clonal prolif of lymphoblasts accum of leukemic blasts in BM
and other tissues.
Can mimic AML
Overlap w/ lymphomas
o If its mainly marrow/leukemic phase ALL
o If its mainly lymph nodes Lymphoma
Most common cancer in Children
Types divided whether B cell line (majority) or T cell line
Signs
o Anemia/thrombocytopenia/neutropenia
o Fatigue/bleeding/infections/fevers night sweat, weight loss, bone
pain
o Heptomegaly/Splenomegaly and lymphadenopathy = more
common in ALL than AML
o Testicular swelling
o CNS involvement Cells seen in a CSF sample
Dx
o Morpho
Cells medium size/High N:C ratio
Nuclear folds/grooves
BM hypercell
No granules/No Auer Rods
o Stain
Myeloperoxide, Sudan Black, and nonspec esterase = Negative
PAS dot like positivity around nucleus
TdT Terminal deoxynucleotidyl transferase
o Flow cytometry
B Cell CD10, CD19, CD20, CD22
T Cell CD2, CD3, CD7
o Cytogenetics
T9:22 Philadelphia chromosome (seen in ALL and CML)

 Complications peripheral neuropathy/AIHA/thrombocytopenia

Lymphadenopathy w/o lymphocytosis

BENIGN LYMPHOCYTE DISORDERS

Lymphatic system
o Primary organs = BM and Thymus
o Secondary = Spleen, Lymph nodes, Tonsils, Peyers patches
Lymphocytosis/Lymphadenopathy
Presentation
o Acute onset + young pt viral syndrome
o Asymptomatic older pt or constitutional symptoms malignant
If symptomatic benign
o Assoc findings Lymphadenopathy > 5cm malignant
CBC
o Mild anemia, mild thrombocytopenia benign
o Severe anemia, severe thrombocytopenia malignant
Morphology
o CLL have normal morph
o Activated reactive lymphocytes can look like blasts
o Cleaved nuclei lymphoma
o Red cell hugging Infectious Mononucleosis
Infectious Mononucleosis
Definition self-limited, acute febrile caused by EBV
Patho expansion of T cells reactive against EBC infected B cells
Clinically
o Affects young people/stiff neck
Dx Downey cells

Lymphatics divided into

o Superficial nodes accessible to physical exam
o Axial nodes assessed by imaging
Causes mediastinal widening
Onset
o Rapid (days) infection or very aggressive lymphoma
o Very slow (mo/years) low grade NHL, CLL
Pain/tenderness
o Yes = infection or very aggressive lymphoma
o No = lymphoma
Node consistency
o Soft = benign
o Firm = NHL
o Rubbery = HL
o Woody hard = metastatic carcinoma
Labs
o CBC, serology, cultures, flow cytometry
o Node biopsy if all other work ups Negative
Hyperplasia benign/reactive lymphadenopathy
Neoplasia malignant
Types of Lymph Node hyperplasia
o Follicular = stim of B cells
Bacteria/viral/auto immune (RA)
o Paracortical = stim of T cells
Drug rxn/Inf Mono
o Sinus = expansion of sinus histiocytes
Sinus histiocytosis + massive lymphadenopathy = RosaiDorfman Disease
Whipple disease
o Angiofollicular hyperplasia = Castlemans disease

Castlemans Disease
Definition = lymphadenopathy due to angiofollicular hyperplasia
o Unicentric = localized
o Multicentric = HHV 8 assoc 50% of the time
Disease course
o Indolent, benign = UCD
o Aggressive, lymphoma like = MCD
Subtypes
o Hyaline vascular type
Most common / UCD / good prog
Onion peal mantle zone / lollipop appearance
o Plasma cell / plasmablastic type IL-6 driven
MCD / more aggressive / symptoms / Tx like myeloma
o Mixed type
Key events
o Viral homologue of IL6 drives B cell prolif
o HHV 8 infects IgM + nave B cells
o Cells go to mantle zone of node follicle
o Cytokine release causes disease symptoms
Tx
o UCD = surgical resection of node
o MCD = no standard tx

Immunodeficiency/Lymphopenia Brutons Disease = X-linked

agammaglobulinemia
Lymphopenia usually assoc w/ ID
When to suspect ID ? recurrent infections
How to Dx?
o Absolute Lymphocyte count (ALC)
o T and B cell counts in PB (flow cytometry)
o Immunoglobulin quantitation in blood
How to Tx?
o IV immunoglobulins monthly
o Tx underlying cause / remove offending agent / gene therapy in
ADA deficiency
Splenomegaly
Criteria need all 3
o Enlargement of spleen
o Reduction of at least 1 cell line in blood
o Normal bone marrow function
Indications for splenectomy
o Splenic rupture
o Chronic immune thrombocytopenia
o Hemolytic anemia: hereditary spherocytosis, AIHA, thalassemia
o Hypersplenism
Dont forget before splenectomy
o Pneumococcal vaccine 2 weeks before
o Annual flu vaccine
o Meningococcal vaccine

MALIGANT LYMPHOCYTE DISORDERS

Chronic Lymphoid leukemias (CLLs)
o Chronic lymphocytic leukemia
o Prolymphocytic leukemia
o Hairy cell leukemia
o Large granular lymphocytic leukemia
o Adult T cell leukemia/lymphoma
Lymphomas
o Hodkin
o Non-Hodkins
Immunoproliferative disorders
o Multiple Myleoma
o Amyloidosis
o Hyperviscosity syndrome
o MGUS
o Waldenstroms macroglobulinemia
Chronic Lymphocytic Leukemia (CLL) B cell

Old age, Men

Not assoc w/ radiation/chemicals/virals as cause
Presentation
o Asymptomatic incidental finding, WBC
o Constitutional weak/fatigue/fever/night sweat/weight loss
o Lymphadenopathy*, splenomegaly, hepatomegaly
o Anemia, thrombocytopenia = BM failure late manifestation
o Infections late in Disease
Staging
o Low
0 = ALC > 5000
1 = ALC > 5000 + Lymphadenopathy
o Intermediate
2 = ALC > 5000 +/- lymphadenopathy + hepatomegaly and/or
splenomegaly
o High
3 = ALC >5000 + Anemia +/- lymphadenopathy +/organomegaly
4 = ALC > 5000 + thrombocytopenia +/- lymphadenopathy +/organomegaly
Flow Cytometry = Standard for CLL
o Weak surface IgM/D (kappa or gamma)
o CD23, Sig+ [weak]
o CD 5 = T cell marker on B cell
CD23+ / Fmc 7 - = CLL
CD23- / Fmc 7 + = Mantle cell lymphoma
Treatment
o Rules for incurable disease
Intent is palliative
Dont have to treat routinely
Therapy
o Stage 0 = observe
o Stages 1, 2 = treat selected
o Stages 3, 4 = Treat
Complications (Exam Q)
o Recurrent infections T/B cell def Pneumonia, Herpes Zoster
o Hypogammaglobulinemia = due to decerase in normal B cells
o AIHA = Warm Ab Coombs + w/ microspherocytes and
polychromatophilic RBCs
o Autoimmune thrombocytopenia (ITP)
o AIHA + ITP = Evens syndrome (+ Coombs/platelets)
o Transformation to Diffuse Large cell lymphoma = Richters
syndrome or prolymphocytic leukemia

Prolymphocytic Leukemia (PLL) B cell (3/4) and T cell (1/4)

Old age
Splenomegaly* w/o lymphadenopathy
High lymphocyte count - WBC
More aggressive than CLL
Cell morpho
o 2x the size of CLL cells
o Large nucleolus = immature
o Clumed nuclear chromatin = sign of mature
Sig+ [bright], CD5 (-), CD23-, FMC7+
Hairy Cell B cell
Old female

 Splenomegaly* w/o lymphadenopathy (like PLL)

Labs
o Pancytopenia = rule (the other 4 all have WBC, HC = WBC)
Due to BM replacement by leukemia cells, BM fibrosis,
splenomegaly
o Dry BM tap
Due to fibrosis of BM induced by hairy cells
o Tartrate resistant acid phosphatase (TRAP) stain +
Hairy cells
o Tropism to BM and spleen
o Hair like cytoplasmic projections due to over expression of Rho
GTPase
Flow cytometry
o Lambda + / Kappa
o CD103 w/ CD19
o CD11c w/ CD19
o CD25 (IL2) w/ CD19
Drug of choice = 2-chlorodeoxyadenosine + rituximab
Good prognosis
Large Granular Lymphocytic Leukemia (LGLL) T cell/NK cell

Neutropenia/anemia
Splenomegaly/arthropathy/positive serology for RA
CD3/CD56/CD57
Tx w/ steroids, cyclophosphamide or G-CSF Neupogen

Adult T cell Lymphoma (ATLL) T cell

Excisional is best
o Priority 2 = Staging/work up after diagnosis is done
o Priority 3 = Treatment after determining stage
Staging
o Stage 1 = one group of nodes
o Stage 2 = 2 or more groups on same side of diaphragm
o Stage 3 = 2 or more groups on both sides of diaphragm
o Stage 4 = organs/tissues not next to nodes and the outside
lymphatic system (Liver BM)
o Then for that stage, see if B symptoms present or not
o PET/CT very useful in staging
Hodgkin Lymphoma (HL)
Itching and alcohol induced pain at site of disease are unique to both
HL and NHL
Malignant cell = Reed-Sternberg cell
in all other cells in biopsy are reactive
Flow cytometry not helpful here since so many cells reactive
immunohistochemistry is standard
R-S cells in HL CD15 and CD30 w/o CD20
Nodular lymphocyte predominant type (NLPHL) has CD20 w/o
CD15 and CD20
Labs
o Normocytic
o Leukocytosis Reactive in HL
o Lymphopenia advanced HL
o Platelets - early and advanced stage
o Disease markers
ESR and C-reactive protein in
Management
o Curable Disease

Young
WBC
Assoc w/ T cell virus type 1 HTLV-1, Japan and Caribbean
Hypercalcemia, skin lesions, hepatosplenomegaly, lymphadenopathy
Non Hodgkin Lymphoma Diffuse Large B cell Lymphoma (DLBCL)
Clover leaf nuclei and T cell phenotype
CD3, CD4
Effacement of lymph node
Poor prognosis
Diffuse proliferation of large atypical lymphocytes
CD19, CD20, and lambda chain
Curable Disease
Indolent/Low Grade NH Lymphomas

HUMAN LYMPHOMAS
Group of heterogenous diseases due to malignant transformation of
lymphocytes in usually lymph nodes (leading to lymphadenopathy)
NHL has way more cases per year
When to suspect
o Painless, non-tender lymphadenopathy
o Spread by contiguity in HL, skip pattern in NHL
o B symptoms
Fever, night sweats, weight loss
Presence of Bs = worse prognosis
Diagnosis
o Priority 1 = Diagnosis lymph node biopsy

Follicular lymphoma grade 1, 2

Small lymphocytic lymphoma (SLL)
Marginal zone lymphoma (MZL)
Lymphoplasmacytic lymphoma Waldenstroms macroglobulinemia
Features of above 4
o Slow growing
o Indolent, affects older patients
o Advanced stage at presentation
o Incurable

Follicular Lymphoma

Prototype indolent NHL

T14;18 and BCL2 overexpression (so inhibit apoptosis)
Incurable
Germinal center markers CD10 and BLC6
Small B cell markers CD20 and BCL2

Marginal Zone Lymphoma

3 subtpyes

o 1 - Involves lymph nodes

o 2 primary Massive splenomegaly w/o lymphadenopathy
o 3 primary extranodal presentation
Most common mucosa associated lymphoid tissue MALT
Assoc w/ H pylori infection
Use of antibiotics complete remission of lymphoma
CD20 and BCL2
Mantle Cell lymphoma

T11;14
Overexpression of Cyclin D1/BCL1
CD19, CD5, CD22, FMC7
Fast growing, incurable

Very Aggressive NHL Burkitt Lymphoma

2 forms
o Endemic(African) Jaw presentation in children, EBV+
o Sporadic (anywhere in world)
o T8:14 and Myc overexpression
o Starry sky and vacuolated cell
o Curable w/ aggressive chemo
T-Cell Lymphoma Mycosis Fungoides

Chronic cutaneous T cell lymphoma

CD4 = Sezary cell ceribriform/folded nuclei
Pruritic, psoriasis like plaque lesions
Skin infiltration by lymphoma cells
Sezary syndrome = MF + circulating lymphoma cells
Chronic/incurable

Anaplastic Large Cell Lymphoma (ALCL)

Skin, bone, lung, liver
CD30 (R-S cells also CD30 but its CD30 and CD15) here only 30
Anaplastic large cell kinase (ALK)
o T2;5 NPM-ALK most common (NPM = nucleophosmin)

IMMUNOPROLIFERATIVE DISORDERS
Definitions
o Malignant prolif of Ig secreting B lymphocytes (plasma cells) and
assoc w/ paraproteinemia (secreted)
o Serum protein electrophoresis (SPEP) analyze proteins in serum
o Polyclonal gammopathy = benign reactive plasma cell response to
antigen

o M-protein or paraprotein = monoclonal band that reflects Ig

synthesis from single clone Monoclonal gammopathy.
o Polyclonal = broad based band
o Monoclonal = narrow based band
Plasma cell disorders classification
o Monoclonal gammopathy of undetermined significance (MGUS)
o Plasma cell myeloma
o Plasmacytoma
o Immunoglobulin deposition disease
Primary amyloidosis
Diagnostic Criteria
o Symptomatic myeloma
Monoclonal protein in serum/urine
>10% plasma cells in BM
CRAB
Calcium (hypercalcemia)
Renal impairment
Anemia
Bone Disease
o MGUS
M protein level <3
<10% plasma cells in BM
No CRAB
MGUS becomes MM
Multiple Myeloma
Definition
o Expansion of malignant plasma cells in BM
o Destructive (lytic) bone lesions
o BM failure
o Consequences of secreted proteins
Plasma cells are in a cluser w/ a perinuclear halo and eccentric nuclei
Myeloma cells normal counterpart is post germinal center plasma
cell
Like their counterpart, they home to bone marrow
With time they expand in the BM and replace normal hemato
Clinical manifestations result from
o BM replacement by myeloma
Plasma cells express CD38 and CD138
Infiltration leads to Anemia, Neutropenia, Thrombocytopenia
which is classic triad for BM failure
o Monoclonal Ig secreted by myeloma cells
Rouleaux formation stacking of RBCs
Erythrocyte sedimentation rate (ESR)
Immune paresis - in normal serum Igs
Renal injury
Bence Jones light chain(k or gam) protein deposition
Amyloid deposition
Calcium deposition (nephrocalcinosis) due to Ca2+
Pyelonephritis
Uric acid crystal deposition
IV contrast should be avoided
MM treatment = bisphosphonates

o Bone resorption
Myeloma cells interact w/ BM stromal cells generate
differentiated and activated osteoclasts Bone resorption
fracture/collapse Pain

 Epidemiology
o African Americans, pacific islanders
o Old people
o Petroleium products and pesticides
MM clinical features
o Bone pain (backache)
Skeletal survey is standard test
Multiple punched out lytic lesions, osteopenia (bone thinning),
compression of vertebral bodies and pathological fractures
Bone scan underestimates bone disease b/c its measuring
osteoblasts
o Anemia
BM infiltration by MM
Renal fail EPO
o Recurrent infections
Neutropenia due to MM
Deficient immunity
o Hypercalcemia
Due to bone resorption
o Amyloidosis
o Hyperviscosity syndrome
Labs for MM
o Presence of paraprotein
SPEP presence of monoclonal spike
IEP type of isotype usually IgG
o serum free light chain
FLC assay has replaced bence jones protein detection in urine
o normal Ig
o Peripheral blood smear
Rouleaux formation
erythrocyte sedimentation rate (ESR)
serum B2 microglobulin made by plasma cells
Prognostic marker
MM is incurable

Malignant prolif of IgM secreting plasmacytoid lymphocytes in BM

Assoc w/ soft tissue and not bone disease
When BM infiltration cytopenia
When liver/spleen hepatosplenomegaly
Monoclonal IgM Hyperviscosity syndrome
Clinically
o Hyperviscosity syndrome
Visual disturbances
Retinal changes
Epistaxis
Tx = plasmapheresis

Plasma Cell Leukemia

>20% plasma cells in blood
Combined features of
o Acute leukemia = anemia, thrombocytopenia
o Multiple myeloma = Ca2+, renal fail, bone disease
Progresses from MM to this disease
Amyloidosis
Definition = extracellular deposition of protein in abnormal fibrillary
form
Systemic Amyloidosis (AL)
o Assoc w/ clonal plasma cell prolif
o Caused by deposition of monoclonal light chains
Clinically Organ enlargement and dysfunction
o Tongue macroglossia
o Heart cardiomegaly
o Peripheral nerves neuropathy
o Kidney renal fail

Waldenstroms Macroglobulinemia

BONE MARROW TRANSPLANTATION

 Hematopoietic stem cell transplant (HSCT)

o 2 phases
Administer high dose chemo and/or radiation elim of tumor
and pts BM
Infusion of hematopoietic stem cells reconstitute
lymphohematopoietic system
Types
o Autologous Pts own marrow/stem cells are removed,
cryopreserved and reinfused after high dose chemo
Done in Multiple Myeloma/NHL/HL
Mechanism of cure = high dose chemo. Allows for dose
intensification and marrow tox is dose limiting
Adv = pt is donor and less toxicity
Disad = pts own stem cell may be abnormal b/c of previous
chemo or contamination w/ tumor cells
o Allogenic Stem cells from a donor
HLA matched sibling donor
HLA mismatched family donor
HLA matched unrelated donor
Done in AML/ALL/MPD/MDS/aplastic anemia/Hb-opathy
Mechanism of cure = high dose chemo and/or radiation
Can replace genetically abnormal (not cancerous) HSC w/ a
normal one ex) Sickle Cell
GVT new stem cell can recognize cancer cell as foreign and
remove them
o Syngeneic from a twin
o Cord blood rich source of stem cells
Hematopoietic Stem cell
o Gives rise to entire system
o Unique property of self renewal so few number of cells needed
o CD34
o Normally in BM but in equilibrium w/ blood
Harvesting stem cells
o BM harvest posterior iliac crest
o Peripheral blood harvest mobilization of stem cells into
peripheral blood followed by apheresis
Use of G-CSF causes this
Other use
o Marrow fail/Hb-opathy/enzyme def/Aplastic anemia/Sickle
cell/Thalassemia
HLA antigens
o Chromosome 6 w/ antigens A, B, C, DR
o Can differentiate self from non self
o Siblings have 25% chance of matching
Phases of Transplantation
o Condition
chemo/rad done to tumor burden and immunosuppress pt to
allow engraftment
o Transplant
harvested cells infused into vein, cells go to BM
o Recovery
2 weeks of intense supportive care
Pt is cytopenic needs platelet and blood transfusion
Reversible damage to skin, liver, GI, lung due to chemo
o Infections
Susceptible to infections
Bacteria = Gram neg/pos
Viral reactivation = HSV, CMV, Epstein Barr
Funal Candida / aspergillus
Unique aspects of Acute Graft vs Host Disease
o Antigenic differences cause donors immune system to attack
patient as a foreign

o Skin, liver and GI are usually attacked

o But theres also anti-tumor activity
PHARMACOLOGY
Warfarin
o Inhibits Factors 2, 7, 9, 10 } all vit K dependent factors
o Protein C and S are natural anticoags and they are inhibited by
warfarin in first time users
Because C and S are depleted first, it is prothrombotic state in
the beginning
o Monitoring
Target INR = 2-3
Below 2 = Clotting
Over 3 = Bleeding
Gut flota and liver disease also INR
o Ne renal clearance
o Vit K intake effect of warfarin
o Metabolic inducer = Rifampin
o Metabolic inhibitor = Amiodarone, Quinolones, TMP-SMX,
Metronidazole
o Acetaminophen INR via pharmacodynamics interaction
o Need to overlap w/ heparin b/c
It takes 5 days for steady state / for factor 2 depletion
Initially prothombotic b/c C and S are depleted
o Pharmacokinetic interaction = result in warfarin build up
TMP-SMX, Amiodarone etc
o Pharmacodynamics interactions = when a drug is known to cause
bleeding is added to warfarin
Aspirin and clopidrogrel
o For High INRs
w/ no bleeding hold warfarin and give Vit K
w/ life threatening bleeding give FFP
o Purple toe syndrome/skin necrosis
Due to protein C deficiency
Onset = 1-10 days after starting warfarin
Dabigatran
o Direct Factor 2 inhibitor
o No INR monitoring
o Ads
Fewer drug interactions, no monitoring, less intracranial
bleeding
o Disad
Short half life(in case pt missed a dose, no anticoag protection)
No antidote
Heavily Renally cleared
More GI bleeding compared to warfarin
Should not beused w/ mechanical heart valves use warfarin
instead
o Pts having surgery who have CrCl>50 should stop 1-2 days before
and if CrCl <50 mL/min should stop 3-5 days before
Rivaroxaban/Apixaban
o Same as dabigatran except this is factor 10 inhibitor
o And theres more drug interaction b/c this also interacts w/
CYP3A4
o No antidote
o Times when you need real time assessment of level of anticoag
but cannot w/ these
Before surgery, Drug-Drug interaction, if pt is noncompliant
o Renal elimination

 Degrades clots
o Indirect Factor 10 inhibitor = Fondaparinux
o Direct factor 2 inhibitor = argatroban, desirudin and bivalirudin
o Thrombolytics
Generates clots
o Factor 7
o Anti-fibrinolytics
UFH and LMWG and indirect inhibitors because they need help of
antithrombin
o aPTT to monitor heparin
o intrinsic and common pathway assessed
o if pt is going to surgery, stop UFH 4-6 hours before
o Protamine is reversal agent for UFH, partially effective for
LMWH
HIT
o Drop in platelet but also a pro thrombotic state
o HIT is seen 3x more in surgical pts than medical pts b/c surgery
provides a sensitizing environemtn
o Besides HIT, TTP and Lupus thrombocytopenia also cause a pro
thrombotic state but also cause a drop in platelets b/c they are
being consumed
o Do not use LMWH if pt has history of HIT due to cross reactivity
Indirect factor 10 inhibitor = Fondaparinux = smallest compared to
UFH and LMWH
o Fondaparinux does not cause HIT
Smaller the size = risk of HIT
Bigger the molecule = shorter the half life
Smallest has most renal elimination
Protamine actually works best against UFH more than Fondaparinux
Anti-thrombin : Direct Thrombin inhibitor = Argatroban
o Argatroban = 1st line Tx for HIT
o Elim via Hepatic
o Monitor via aPTT

Cause a qualitative defect in platelet and not quantitative

So aspirin cannot cause thrombocytopenia
Monitoring = Optical aggregometry
Aspirin inhibits COX1/2 TXA2 Platelet aggregation
Aspirin antiplatelet effect at 80-100 mg/day
Good for arterial thrombosis but ok for venous thrombosis
Hold for 5 days befoe an invasive procedure
Be/cause of platelets half life and irreversible inhibitor effect by
aspirin
P2Y12 Receptor Antagonist antiplatelets
o Clopidogrel
o Prasugrel
o Ticagrelor (reversible)
o Block ADP from binding at receptor
o Clopidogrel
Hold for 5 days before surgery
Poor absorption
Gets effected by CYP219 metabolizers
o Prasugrel
1 step activation instead of 2
No interactions w/ genetic polymorphisms like clopidogrel
Quicker and more potent/prolonged anti-platelet response
o Ticagrelor (reversible)
Quicker offset
Incase you want to stop antiplatelet shortly before a procedure
SE = Bleeding, Dyspnea, Ventricular pauses
Latter 2 due are caused because ticagrelor ATP which causes
an increase in adenosine in the blood
o
o
o
o
o
o
o

Targeted therapy
o Tyrosine kinase inhibitors
o Hypomethylating agents
o Anti-CD20 monoclonal antibodies
Anti-metabolites
o Anti-folates
o Anti purines
o Anti pyrimidines
Tyrosine Kinase inhibitors = Imatinib, Dasatinib, nilotinib
o Inhibits prolif of bcr-abl fusion protein/Philadelphia chromosome
o Helpful in CML
o Dasatinib
Dual specific ABL and Src kinaser so even stronger
o SE: Edema seen in Imitinib and Dasatinib = off-targets

Factor 7
o To control bleeding
Hypomethylating agents = Azacitidine and Decitabine
o Either through tissue factor independent pathway
o Inhbit DNA methyltransferase hypomethylate dna
o Or tissue factor dependent
epigenetic silencing
o SE = thrombosis
o Helpful in MDS
o Thrombotic events assoc w/ factor 7 occur more in nonHemophiliac pts vs their hemophiliac counterparts
Anti-CD20 Monoclonal antibodies = Rituximab
Critically ill pts have activated platelet all over and this wide
o Opsonized B cells in 3 diff ways
spread activation results in a higher thrombin burts even outside
o But also decreased Ig
the site of injury aka puts them in a pro-coagulant state
o So vaccines given after rituximab dont work
Anti-Fibrinolytics = Aminocaproic acid and Tranexamic acid
o MOA = saturation of the bidning site by anti-fibrinolytics
displaces plasminogen from surface of fibrin
o This prevents binding of fibrin to plasmin and preserve the matrix
structure of fibrin
Aspirin

Antimetabolites
o Interfere w/ DNA synth by falsely substituting in so they are
effective most in tumors that have high proliferation
Folate Antagonist = Methotrexate
o Impairs folic acid intake by tumor cell
o Inhibits DHF reductase
o Antidote = Folinic acid

 Also given a day after to decrease Side effectsr

o Also used for immunosuppressive reasons
Treatment for Rheumatoid arthritis
o Toxic to normal healthy cells that are also rapidly proliferating
GI = diarrhea and mucositis
BM = myelosuppression
Pyrimidine antagonists = Fluorouracil or 5 FU
o Act as a fake pyrimidine base that inhibits thymidylate synthase
o Folinic acid given w/ 5-FU acts to help increase the effect of 5FU
o 5FU as IV bolus myelosuppression
o 5FU as continuous infusion skin toxicity Hand foot syndrome
D
Pyrimidine antagonists Cytarabine and Gemcitabine
o Incorporates into DNA replication
Purine Antagonist = 6 Mercaptopurine and 6 thioguanine
o Decoy for hypoxanthine and guanine
Anti metabolite Hydroxyurea
o In sicke cell , it helps by stimulating production of HbF
o Antimetabolits have immunosuppressive effect by inhibiting
lymphocytes

HEMOSTASIS
Platelet production
o From cytoplasmic frags of BM megakaryocytes
o Live for 7-10 days
o Non nucleated
o Contain mRNA and all organelles and can make proteins
o Megakaryocytes go through Endomitotic synchronous nuclear
replication
Replicate only nucleus and granules and keep getting big as 1
cell
o Thrombopoietin
Made by liver and kidneys
Binds to c-MPL receptor of megakaryocytes
Platelet granules
o Dense Delta granules
Dark on EM
ADP, ATP, 5HTP, Ca2+
Def of these granules = Delta granule storage pool deficiency
o Alpha granules
Adhesion proteins
Fibronectin, thrombospondin, vWF, fibrinogen
Growth promoting factors
Coagulation factors
Platelet function
o Vasoconstriction
o Platelet plug = primary hemo
o Clot/fibrin formation though coag cascade = secondary
o Dissolution of clot = fibrinolysis
Platelet Adhesion
o Blood is not exposed to subendothel collagen which induces
platelet aggregation
o Adhesion to collegen via vWF
o Platelets have gp2b/3a receptor fibrinogen, VWF
o Platlets have gp1b/5/9 receptor insoluble VWF
Von willebrand factor
o Receptor for factor 8, collagen, gp1b/5/9 and gp2b/3a
o Produced in endothelium
o Stored in Weibel Palade bodies in endothelium
Formation of Thomboxane TXA2
o Platelet adhesion and activation at cAMP and Ca2+
o Platelet adhesion
Stimulated by ADP, TXA2
Inhibited by NO, Endothelial ADPase, PGI2, aspirin,
prostacyclin
Primary hemostatic plug
o ADP is a potent recruiter of more platelets
o Clopidogrel works by inhibiting platelet ADP receptor P2Y12

o ADP receptor P2Y12 is assoc w/ moderate bleeding

Defects in platelet aggregation
o Glanzmann involves gp2b
o Von Willebrand and Bernard Soulie involve gp1b
Coag Cascade
o Common = 10, 5, 2, 1
o Extrinsic (PT) = 7 (inhibited by warfarin)
o Intrinsic (PTT) = 12, 11, 9, 8
Vitamin K
o Coarboxylation of gamma carbon of glutamic acid
o Affect factors 10, 9, 7, 2, S, C

Secondary Hemostasis
o Coag starts by tissue factor exposure which then binds 7
o 7+TF
Stim common pathway at factor 10
Stim intrinsic pathway at factor 11
o Formation of cross linked fibrin
Fibrinogen thrombin fibrin that are non cross linked lattice
Factor 13 makes it cross linked
Natural anticoagulants
o Tissue factor pathway inhibitor inhibits TF
o Antithrombin inhibits 9, 19, 2
o Protein C and S inhibit 8 and 5 and TPAI
Fibrinolysis
o tPA = serine protease that converts plasminogen to plasmin
o Plasmin causes fibrin to break down into D dimers
Disorders of Hemostasis
o Disorder of 1 hemostasis
Vascular disorder (platelet dysfunction) immediate bleeding
into mucous membrane and skin
Manifestations
Easy bruising
Spontaneous bleeding from skin/mucous membrane
Menorrhagia
Excessive bleeding after trauma
o Disorder of 2 hemostasis
Clotting factor problem delayed bleeding into joint and soft
tissue
Manifestation
Hematoma collection beneath skin
Hemarthrosis bleeding into joint
Tests to Assess platelets
o CBC
Platelet count
Mean platelet volume inversely related to platelet count
o Blood smear
o Bleeding Time
time = defect in platelet, vWF or vascular defect but NOT
clotting factor defect
Replaced by PFA-100 assay
o Aggregation
Add segregating agent to platelet rich plasma

No agonist = more light scattering

w/ agonist (to induce platelet aggreg) = less light scattering
o Platelet aggregation assay
ADP, Epi, Collagen and TXA2 aggregate platelets through
Gp2b/3a and fibrinogen
Ristocetin aggregates platelets through
Gp1b and vWF
Biphasic aggregation seen due to ADP being released twice
o PFA100
Tests adhesion and aggregation in response to agonst
Measures time needed for occlusion
Collagen + Epi prolonged by Aspirin
Collagen + ADP prolonged by Clopidagrol

Tests to assess clotting factors

o Prothrombin (PT) Time
Extrinsic and common pathway
Sensitive to Vit K factors 2, 7, 9, 10
Used for monitoring warfarin
INR to standardize
o PT time in
Liver disease decreased clotting factors production
Vit K antag Warfarin
Fibrin or fibrinogen degradation products as in DIC
o Partial thromboplastin time (PTT)
Intrinsic and common
Screen for detection of coag inhibitors (lupus anticoag)
Used for monitoring heparin and factor replacement therapy w/
hemophilia
o PTT time in
Heparin inhibits 10 and 2
Fibrin or fibrinogen degradation products
Lupus anticoagulant
Liver Disease
o Mixed study
Mix normal control plasma w/ patients plasma
If pts Pt or PTT value is corrected pts initially prolonged
time due to factor deficiency
If not corrected its due to presence of inhibitor
o Thrombin Time (TT)
Measures thrombin induced conversion of fibrinogen to fibrin
o TT time
Afibrinogenemia
Hypofibrinogenumia
Dysfibrinogenemia
Acquired
Disorders involving Primary Hemostasis
Vascular disorder
o Easy brusing and spont bleeding from small BV
o Abnormality is vessels or pervasc CT
o Inherited
Hereditary hemorrhagic telangiectasia
Elhers-Danlos syndrome

o Acquired
Scurvy
Senile purpura
Purpura assoc w/ infection
Henoch-Schonlein syndrome
Hereditary hemorrhage telang.
o Also called Osler Weber Rendu syndrome
o Auto Dom
o Dilated microvasc swelling
o Tx w/ laser, embolization, estrogen therapy
Ehlers Danlos syndrome
o Mutation in collagen gene
o Purpura/hyperextensibility/dissecting aneurism
o USMLE gives this as a child abuse case
Scurvy
o Vit C def defective collagen perifollicular petechiae (old)
Senile purpura = atrophy of supporting tissue of cutaneous bv
Purpura assoc w/ infection
o Many diff ones. DIC meningococcal septicemia
Henoch-Schonlein
o In children w/ URTI
o Its a IgA mediated vasculitis
o Purpuric itchy rash on but and lower legs

o Platelet transfucion is contraindicated

o Lifespan of platelet is normal so they dont bleed
LDH + adult + thrombocytopenia + neuro symptoms = TTP
LDH + kid + thrombocytopenia + renal = HUS
Disorders of platelet Function
o Hereditary
Glanzmanns Thrombasthenia
Bernard Soulier
Storage pool disorder
May Heggland
o Acquired
Antiplatelet drugs
Hyperglobulinemia plasma cell myeloma or Waldenstroms
macroglbulinemia
Myeloprolif or myelodysplast disorder
Glanzmanns Thromboasthenia (GT)
o Auto rec
o Fail of platelet aggreg due to fibrinogen receptor def (gp2b/3a) on
platlets
o Dx by platelet aggregation study
Abnormal platelet aggreg w/ ADP, Epi and collagen
Normal platelet aggreg w/ ristocetin (via gp1b)

Platelet Disorders
Quantitative Thrombocytopenia
Qualitative +/- thrombocytopenia
Causes of thrombocytopenia
o destruction
Autoimmune = ITP, TTP, HUS
o Production
BM failure aplastic anemia, neoplasia
o Sequestration
Splenomegaly
Autoimmune thrombocytopenic purpura ITP
o Due to platelet destruction
o Chronic ITP
More common
Cause of isolated thrombocytopenia
Autoantibodies against platelet receptors
BM = megakaryocytic hyperplasia
Tx = steroid, IV IG, Rituximab
o Acute
In Children
After vaccination or infection (chicken pox or mono)
Due to nonspecific immune complex
Post transfusion purpura
o Antibodies in recipient against HPA-1a on transfused platelets
Drug induced quinine, quinidine, heparin
Thrombocytopenia due to thrombotic thrombocytopenic purpura
TTP
o Deficiency of ADAMTS13 ( usually breaks down large VWF)
o Neurological symptoms
o Tx = plasma exchange w/ FFP that removes the vWF and autoAb
o Platelet transfusion is contraindicated
Hemolytic Uremic Syndrome HUS
o In children
o Kidney dmage
o Assoc w/ E coli 0157-H7 infection

Bernard Soulier
o Auto Rec
o Failure of aggreg due to vWF receptor (gp1b) on platlets
o Smear = anemia, thrombocytopenia, large platelets
o Dx by plat aggreg study
Normal aggreg w/ ADP, Epi and collagen
Abnormal aggreg w/ ristocetin
Same is seen in VWF disease
Bleeding tendency + thrombocytopenia + large platelets + no
response to ristocetin = BSS
Bleeding tendency + No thrombocytopenia + normal platelets + no
response to ristocetin = vWD
May Heggland anomaly
o Auto dom
o Mutation in myosin heavy chain MYH9
o Pts have Alport syndrome = hereditary nephritis w/ sensorineural
o Smear
Giant platelets
Dohle bodies in WBC
Thrombocytopenia
Storage pool disorder
Grey platelet syndrome
o Auto rec due to NBEAL2 gene mutation
o Smear
Large platelets w/ no granules +/- Thrombopenia
o Agranular platelets also seen in MDS
Delta SPD disorder
o Hermansky pudlack oculo-cutanous albinism
o Chediak Higashi partial albinism; large granules

o Wiskott Aldrisch X linked, eczema, thrombpenia, repeated

infection due to immune def)
Disorder of platelet function - acquired
o Antiplatelet drugs
Aspirin, NSAIDS
o Hypergamaglobulinemia = plasma cell myeloma or
Waldenstromss
o Myeloprolif, Myelodysplast, PNH
o In aggreg assay
Aspirin aggreg w/ Epi
Clopidogrol aggreg w/ ADP
o In PFA100 assay
Aspirin prolonged closure time of coll + epi cartridge
Clopidogrol prolong closure time of coll + ADP cartridge

o
o
o
o
o
o

Disorders involving Secondary hemostasis

Hereditary Coag disorders
o Hemophilia A (F8 def)
o Hemohilia B (F9 def)
o VWD
Hemophilia A
o X linked
o Def in Factor 8
o Infants have profuse hemorrhage or develop joint/soft tissue
bleeds and brusing when they start to get active
o Recurrent painful hemarthroses Joint deformity

Labs for Hemophilia A and B

Prolonged aPTT
Low level of F8 (f9 for B)
Normal bleeding time and PT
o Detection
DNA analysis
DNA from chorionic biopsy
Antenatal Dx possible
Treatment of HA
o Bleeding episodes treated w/ Factor 8 replacement
o Spont bleeding controlled if F8 is raised above 20% of normal
o For surgery it should be raised to 100%
Factor 9 Def
o X linked
o Christmas disease
o The 2 disorders only diff by coag factor assay
o F9 has longer half life so infusions less frequently needed
Von Willebrand disease Exam Q
o Reduced level/fxn of vWF due to pt mutation or deletion
o vWF has 2 roles
promote platelet adhesion to damaged endothel
Carry Factor 8 and protect from breakdown
o bleeding time
o Auto dom except 2N and type 3 AR
o Mucous membrane bleeding, blood loss from superficial cuts and
abrasions
o Type 3 have no VWF at all

Looks like clotting factor def

Hemarthrosis and hematomas
Labs
bleeding time but normal platelet #
Factor 8
PTT
Platelet aggreg
Defective aggreg w/ Ristocetin
Normal aggreg w/ ADP, Epi, collagen
Type O blood usually have lowest levels of vWF
Type 1 all present but $
Type 2A = no large and intermediate
Type 2B = No large and affin for Gp1b
Type 3 = None at all
Type 2N
Inability of vWF to bind to F8 low levels of 8
vWF level is normal and aggreg normal w/ ristocetin
Type 2M
Inability of vWF to bind to Gp1b on platelet
vWF antigen levels are normal w/ decreased ristocetin activity
Treatment
DDAVP for type 1
F8 concentrate
Note WF is an acute phase reactant and could be due to preg,
exercise or stress

Acquired Coag Disorders

o Vit K def diet/drugs
o Liver Disease biliary obstruct cant absorb vit K

Disseminated intravascular coagulation DIC Exam Q

o Widespread deposition of fibrin w/ consumption of coag factors
and platelets
o Occurs due to many diseases
o Bleeding and thrombus
o Labs
PT, PTT, TT
fibrinogen, platelet count
FSP and D dimers
o Smear
Hemolysis and RBC frags (schistocytes)
o Tx
Supportive care w/ FFP and platelet concentrates
Cryoprecipitate provides more concentrated source of
fibrinogen and RBC transfusion
DO NOT use heparin or antiplatelet drugs
General Roles in Thrombosis testing
o Tests affected by acute phase response and anticoag therapy
AT, PC, PS, clotting factors and fibrinogen
So test 3 months after episode and off therapy for 2 weeks
o DNA based tests and homocysteine test are not affected by acute
phase response
Testing for inherited thrombophilia

o Test for 5 leiden (most common)

o + ? = stop
o - = Test for prothrombin
Factor 5 Leiden
o Factor 5 gene w/ single base pair substitution, Arg to glut
o Protein C = natural coag and usually inactivates 5 but after this
mutation, its less susceptible (activated protein C resistance)
o FVL mutation hypercoagulable state = risk for VTE
o Heterozygous for factor 5 are 5 fold risk for VTE
o Homozygous are 50 fold
o Test methods
APC resistance assay
DNA based assay PCR
Activated protein C resistance assay
o APC will prolong PTT of normal but not of FVL = resistant
Prothrombin G20210A mutation
o Prothrombin Factor 2 = precursor of thrombin
o Made in liver
o prothrombin levels thrombotic risk
o Test = PCR
Protein C deficiency
o Auto dom
o Vit K dep
o Develop Skin necrosis due to Dermal vessel occlusion when
treated w/ warfarin therapy
o Def occurs during liver disease, DIC and sepsis
Protein S deficiency
o Cofactor to C
o Same necrosis w/ warfarin
Antithrombin Deficiency
o Natural anticoag that inhibits 2a and 10a
o Arterial thrombosis occurs
o Heparin ineffective
o Seen in pts w/ Nephritis
Homocysteinemia

o levels of homocysteine = Both venous and arterial thrombosis

o Mutation in methylene tetrahydrofolate reductase = MTHFR

Antiphospholipid Antibodies APL

o Ab against plasma proteins bound to anionic surface
(phospholipid)
Anticardiolipin
Beta2 glycoprotein 1 (B2 GP 1)
o Occurs as thrombosis or recurrent miscarriage in assoc w/ APL Ab
o 1 type is lupus anticoagulant
Prothrombin or B2 glycoprotein I
o Venous and arterial thrombosis
ISTH criteria for lab Dx of APL
o Prolongation of atleast 1 phospholipid dependent screen test
PTT, Dilute Russell viper venom, Kaolin clotting
o No correction w/ 50:50 mix
o Correction suggestions clotting factor deficicny
o Correction when excess phospholipid is added
Children w/ APL Ab
o Post viral adenovirus, varicella
o Autoimmune juvenile arthritis, SLE, AIHA
o Prolonged PTT but no risk of bleeding