Anaemias, polycythaemias.

Robert Moore.

23/10/08 1
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 Anaemia: objectives
• Know common classification systems for anaemia
diseases.
• Know the causes for small and pale red blood cells
and laboratory tests for diagnosis and treatment.
• Know the causes for normal but insufficient rbc
and lab tests……
• Know the causes for rbc of increased size and lab
tests……

23/10/08 3
 Anaemia, classification:

• By appearance – laboratory
focus

• By cause – clinical focus.

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 Appearance: microcytic,
hypochromic (small and pale), the
symptoms of anaemias:
• Pallor
• Fatigue
• Decreased exercise tolerance
• Dyspnoea
• Palpitations
• Oedema
• Irritability
• Poor feeding
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Microcytic, hypochromic anaemia,
causes:
• Iron deficiency
• Thalassaemias
• Pyridoxine (vitamin B6) deficiency
• Infections
• Lead poisoning

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 Microcytic hypochromic anaemia,
causes:
• Bleeding from the gut (hookworm in tropics,
gastrointestinal cancer in the elderly)
• Menstrual bleeding
• Pregnancy
• Malabsorption
• Malnutrition
• Urinary tract bleeding
• Pulmonary haemosiderosis

23/10/08 7
 Microcytic hypochromic
anaemia, the lab tests:
• Serum Ferritin
• Serum Iron
• Serum TIBC or transferrin.
• Bone marrow iron

23/10/08 8
 Iron deficiency anaemia:
management
Find cause: gastrointestinal,
gynaecological,
haematuria,
lungs (X ray),
faeces – “occult” blood.
20% no cause found.
23/10/08 9
Iron deficiency anaemia, treatment:
• Oral iron FeSO4 200 mg 3 x /day
• Nausea
• Epigastric pain
• Diarrhoea or constipation
• 6 months of therapy
• Hb up by 20g/L each 3 weeks for success.
• Failure to respond then wrong diagnosis, non
compliance, malabsorption, continued bleeding.

23/10/08 10
 30 year old vegetarian is tired,
microcytic, hypochromic
• Blood Haemoglobin 90 g/L (110-150)
• Erythrocytes 4.2 x 1012 /L(4.5-6.5)
• Haematocrit 0.3 (0.35-0.45)
• Serum iron 7 umol/L (10-30)
• Serum TIBC 69 umol/L (40-70)

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 Appearance: normocytic,
normochromic, causes:
• Blood loss
• Haemolytic
• Chronic disease – infections,
uraemia, endocrine
• Bone marrow infiltration
• Aplastic or hypoplastic
• Anaemia of pregnancy
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 Haemolytic anaemias:
Haemolysis because of abnormal Hb:
thalassaemia, sickle cell anaemia
Haemolysis because of abnormal
membrane: spherocytosis, elliptocytosis
Haemolysis because of abnormal
metabolism: G-6-PDH, PK
Acquired: immune, iso-immune, non immune

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 Haemoglobin:
• Normal Hb
• HbA 97% (a2b2 chains)
• HbA2 (a2d2)
• HbF (a2g2)
• Gower 1, Gower 2, Portland

• Variant Hb, 800 known.

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 Haemoglobin variants, these may
give haemolytic diseases:
• S (sickle) (a2bs2)

• C (a2bc2)
• E (a2be2)

• G Philadelphia (ag2b2)
• O Arab (a2b02)
• D Punjab (a23bd2) + 800 more
23/10/08 16
 Clinical Indications for Hb
testing:
• Preanaesthetic screening for sickle cell
haemoglobin, HbS.
• Antenatal screening for genetic counseling
and maternal management. HbS, C, D, E, F,
Lepore, O Arab, thalassaemias.
• Neonatal screening for HbS and beta-
thalassaemia.

23/10/08 17
 Beta-thalassaemia
Minor: BBo, no symptoms.
Major: BoBo
• Severe anaemia at 3-6 months, Hb < 70 g/L.
• Microcytic, hypochromic anaemia.
• HbF could be 65-100%.
• Iron overload
• Abnormal growth.
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 Beta thalassaemia management
• Blood transfusions
• Iron chelation (desferrioxamine for 5-7 days
a week)
• Splenectomy
• Genetic counselling
• Bone marrow transplant

23/10/08 20
 15 year chinese girl,
hypochromic, reticulocytosis.
b-Hb 86 g/L (110-150)
Mean cell volume (MCV) 22 (26-33)
rbc 4.4 x 1012 /L (3.8-5.6)
Reticulocytes 5.5% (0.5-2.5)
b-Hb electrophoresis: alpha/beta 0.6/1 (1/1)

• What is diagnosis?
23/10/08 21
 5 year-old child, italian parents.
• Frequent upper respiratory tract infections.
• Fever.
• Anaemia.
• Abdominal ascites.
• Enlarged spleen.
• Legs swollen.
• Thalassaemia.
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 Sickle cell anaemia
• 6-9 months anaemia, jaundice, dactylitis
and splenomegaly.
• Painful crisis when sickling cells block
blood vessels.
• Diagnosis is by blood smear (film),
electrophoresis, sickling test.

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 Sickle cell anaemia
• Virus or folate lack causes crisis
• Complications: genitourinary, skin, eyes,
hepatobiliary.
• Failure of spleen, cerebral infarct,
glomerulosclerosis, osteonecrosis,
retinopathy, lung disease.

23/10/08 26
 Sickle cell trait, is it a problem?
• Study of 2 million enlisted recruits in the
US armed forces showed that recruits with
sickle cell trait were 40 times more likely to
die during strenuous exercise than others.
• Physician and Sports Medicine 15 #12,
1987.

23/10/08 27
 15 year old Afro -Canadian girl
• Pain in arms and legs
• Blood haemoglobin 80 g/L (115-165)
• Hct 0.097 (0.34-0.44)
• Erythrocytes 4 x 1012/L (4.5-5.9)
• Leukocytes 50 x 109/L (5-10)
• Serum iron 2.1 umol/L (9-30)
• Albumin 32 g/L (45-50)
23/10/08 28
 Hereditary spherocytosis and
elliptocytosis
Spherocytosis: Autosomal dominant
• Northern Europe 1%.
• Defect in spectrin.
• Variable severity.
• Treatment by spleen removal.
Elliptocytosis: very rare.
• Cells are destroyed by spleen, splenomegaly, mild
anaemia

23/10/08 29
 Glucose-6-phosphate
dehydrogenase deficiency
• X chromosome
• Black males 15% but also found in S Europe,
middle east, SE Asia populations.
• Newborn or when oxidative stress happens.
• Sensitive to some analgesics, antimalarial drugs,
Fava beans, infections.
• Possible cause of infertility (National Post story).
• Blood transfusions may be needed

23/10/08 30
 Pyruvate kinase deficiency
• Autosomal recessive
• Erythrocytes cannot make sufficient ATP
and become rigid
• Increase in intracellular 2,3
diphosphoglycerate which helps to release
oxygen from Haemoglobin and symptoms
of anaemia are reduced.

23/10/08 31
 20 year-old Amish woman has
weakness
• Abdominal pain, jaundice and
splenomegaly.

• Blood Hb is 109 g/L (110-165)

• Haematocrit is 0.27 (0.37-0.47)
• Reticulocytes 4.5% (0.5-2)

23/10/08 32
 Acquired haemolytic anaemias –
warm (IgG)
Primary –
• Idiopathic
Secondary –
• Lymphoproliferative
• Neoplasia
• Connective tissue
disease.
• Drugs
• Infections

23/10/08 33
 Acquired haemolytic anaemias-
cold (IgM)
Primary –
• Cold
haemagglutination
Secondary –
• Lymphoproliferativ
• Infections
• Paroxysmal cold
haemoglobinuria

23/10/08 34
 Isoimmune haemolytic anaemia
• Haemolytic blood transfusion reactions and
haemolytic disease of the newborn
• Mother is Rhesus negative (Rh-) and father is
Rhesus positive (Rh+)
• First pregnancy with Rh+ foetus is not harmed but
mother makes antibodies against subsequent Rh+
foetuses
• Mother’s antibodies cross the placenta and
damage the foetus’s erythrocytes

23/10/08 35
 Alvaro Domecq. Dead after 88
years.
• Sherry grandee
• Bullfighter
• 19 children
• 14 dead at birth
• 2 survived to
adulthood
• Globe and Mail 2005
october

23/10/08 36
 Microangiopathic haemolytic
anaemia, causes:
• Haemolytic uraemic syndrome
• Thrombocytopenic purpura
• Carcinomatosis
• Vasculitis
• Severe infection
• Pre eclampsia
• Glomerulonephritis
• Malignant hypertension
23/10/08 37
 Anaemia of chronic disease:
• Rarely severe
• Increased erythrocyte destruction, shortened
life span
• Could be excessive production of
interleukin-1 by macrophages.
An inflammatory disease

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 Anaemia of chronic disease,
causes and treatment:
Causes:
• Malignancy
• Rheumatoid arthritis
• Some connective tissue diseases
• Chronic infection
• Extensive trauma

Treat by blood transfusion or EPO

23/10/08 40
 Aplastic anaemia – bone marrow
failure
• Pancytopenia – all cells reduced
• Uncommon 2-5/1,000,000. Any age,
both sexes
• Clinical: anaemia
frequent and severe infections

23/10/08 41
 Aplastic anaemia: diagnosis
• CBC
• Blood smear – precursor cells, blasts
• Bone marrow - increase in fat spaces >75%
• Tests for cause: liver,
Virus,
Fanconi’s in children

23/10/08 42
 Aplastic anaemia: management
• Removal of cause: drugs such as cytotoxic
agents, phenylbutazone, indomethacin,
penicillamine, carbamazepine, phenytoin,
chloramphenicol, sulfonamides, gold salts
• Supportive care: blood and platelet
transfusion
• Immunosuppression works in 50-70%
• Bone marrow transplant

23/10/08 43
 Sideroblastic/cystic anaemia:
• Normoblasts with non Hb Fe
• Defective haem
• Hereditary sideroblastic anaemia: males,
MCHC and reticulocytes decreased, iron
increased, bone marrow loaded with iron.
Defect: first step in protoporphyrin synthesis.
• Acquired: idiopathic, secondary e.g. Pb,
alcohol
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 Appearance: macrocytic/
megaloblastic anaemia, causes:
vitamin B12 and folic acid deficiency
• Small intestine disease
• Liver diseases
• Hypothyroidism
• Pregnancy
• Interference with DNA synthesis
• Haemolytic anaemia with reticulocytes
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 Macrocytic (megaloblastic)
anaemia
• Deficiency of vitamin B12
or folate
• Vit B12 - malabsorption
• Folate - dietary lack but
Vitamin B12 deficiency
should be excluded or
corrected before treatment
with folate.

23/10/08 47
 Macrocytic (megaloblastic)
anaemia, clinical:
• Loss of vibration sense
• Ataxia
• Hyperactive reflexes
• Weakness: spastic or flaccid

23/10/08 48
 Macrocytic (Megaloblastic)
anaemia
• “Pernicious anaemia” – an
autoimmune disease
• IgG against gastric parietal cells give
lack of “intrinsic factor”
• Problem for women of north European
descent.

23/10/08 49
 Macrocytic (megaloblastic)
anaemia – diagnosis:
• Erythrocytes larger than normal, oval, a
variety of sizes - poikilocytosis
• Tongue is smooth, red and inflamed
• Serum vitamin B12 < 100 ng/L
• Serum folate < 3 ug/L or combination of
lack of these vitamins
• Schilling test –obsolete.

23/10/08 50
 Macrocytic (megaloblastic)
anaemia, treatment:
• Vitamin B 12; IM injections for a time.
Once cured 1 injection each 3 months for
life.
• Folate: orally 5 mg daily for several
months.
• Folate may be given in pregnancy to
prevent spina bifida.
• Folate has been added to flour.
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 Macrocytic anemia

• Cheaper to treat by dietary

means than to test for it! In
particular for folate lack.

23/10/08 52
 Old man, tired, cold intolerant, feet
numb, sore tongue, pale, icteric
blood-Haemoglobin 64 g/L (135-170)
Mean corpuscular volume MCV 131 fL (80-100)
Leukocytes 3 x 10^9/L (4-11)
Platelets 63 x 10^9/L(150-400)

• What does he have and how can you diagnose it?

Macrocytic anaemia,
Blood smear, bone marrow, serum bilirubin, vitamin
B12, folate, serum homocysteine.
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 Polycythaemia – symptoms:
• Increased blood
viscosity
• Malaise
• Fatigue
• Headache
• Congestive heart
failure
• Cyanosis

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 Polycythaemia – causes:
Hypoxia High altitude, hypoxic lung disease,
cyanotic heart disease, smoking,
abnormal Hb with decreased oxygen
affinity
Inappropriate Renal disease, hepatoma, cerebellar
secretion of EPO haemangioblastoma,
pheochromocytoma, fibroids.
Other Neonatal polycythaemia,
Hypertransfusion
23/10/08 56
 Polycythaemia
• Idiopathic erythrocytosis
• Apparent polycythaemia: middle aged
men. Obese, hypertensive, on diuretics,
alcohol and tobacco.
• Polycythaemia rubra vera:
myeloproliferative disease, pruritis,
itchiness, at risk for strokes, gout.
Splenomegaly. Red faced.

23/10/08 57
 Polycythaemia – diagnosis:
Blood Hb males > 175 g/L
females > 160 g/L

• Kenyans > 200 g/L

• Canadian marathon runners’ average Hb
145 g/L (1976)

23/10/08 58
 IAAF/IOC wants to detect blood
doping/boosting
• By infusing your own packed erythrocytes.
(Finns and Italians)
• By injecting erythropoietin. (Woman winner
of Ironman 2004 failed for this)

• How can the laboratory be useful in each

case?

23/10/08 59
 Small and pale erythocytes:
Anaemia Test. Treatment.
cause.
Iron deficiency CBC, Iron,
s ferritin, s absorption
iron, enhancers
s total iron
binding
Beta CBC, Hb Transfusion
capacity
Thalassaemia. electrophoresi chelation
Lead poisoning sCBC, film, u Chelation.
23/10/08
or s lead 60
 Normal but fewer erythrocytes:
Cause. Test. Treatment.
Blood loss Reticulocytes Replace blood
Haemolysis Reticulocytes Tackle cause
Chronic illness Disease markers Tackle cause
Marrow Bone marrow Chemotherapy,
invaded cells transplant
Aplastic Bone marrow Transplant
marrow cells

23/10/08 61
 Big (macro):
Cause. Test. Treatment.
Nutritional. Vitamin B12 and folate Replace vitamins
Haemolytic Hb electrophoresis Steroids, transplant
anaemias
Pernicious Replace intrinsic
anaemia factor.

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 Excesses:
Tests. Treatment
Polycythaemias. CBC, viscosity, Blood letting
EPO.
Haemochromatosi CBC, Fe, total iron Blood letting
s see unit 5 binding capacity,
liver function tests,
glucose.

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 Transfusion medicine

Robert Moore.

23/10/08 64
 ABO antigens
Blood group O A B AB

Rbc antigen none A B A and B

Serum antibody Anti A+B Anti B Anti A 0

Prevalence 47 42 8 3
(UK)

23/10/08 65
 Routine blood testing before
transfusion
• ABO group
• Rhesus group. At least D 85% of UK
• Erythrocyte antibody screen
• Hepatitis Bs antigen
• Antibodies to hepatitis C
• Antibody to HIV-1
• Antibody to treponema palladium (syphilis)
• [USA, antibody to HTLV-1]
23/10/08 66
 Transfusion testing
• Erythrocytes for ABO and Rh – good for
98% compatibility.
• Serum for A and B antibodies
• Antibody screen: serum mixed with three
sets of erythrocytes of known type to detect
haemolytic non ABO antibodies
• Cross matching: serum mixed with the
erythrocytes from each donor.

23/10/08 67
 Erythrocyte antigens +
antibodies, sensitized or
immune, usually IgG
• Rhesus cde/cde
• Anti-D (anti-C, anti-c,
anti-E less common)
Rhesus negative
15% • Anti-Kell
• Kell (K) 9%• Anti-Duffy
• Duffy (Fya, Fyb)
60% • Anti-Kidd
• Kidd (JKa, JKb)
75%

23/10/08 68
 Adverse reactions
Acute Delayed
Non Haemolytic, Septic, Infections,
immune Aggregates, Iron overload.
Lung infiltrate,
Metabolic.
Immune Non haemolytic, Graft versus host,
Acute haemolytic, Purpura,
Platelet.

23/10/08 69
 Transmission of microbial
diseases in transfusions
• Bacterial e.g. Yersinia
• Protozoal e.g. malaria
• Viral, plasma borne:
Hepatitis A (very rare), B, C, HIV-1, HIV-2,
parvovirus
• Cell associated viruses:
Cytomegalovirus, Epstein-Barr virus,
HTLV-1, HTLV-II.
• West Nile virus.
•23/10/08
? CJ disease, “mad cow” (BSE). 70
 Probability of risk/unit of
transfused blood, CRC:
Cytomegalovirus (CMV) 1:5,000
Hepatitis B 1:25,000
Given wrong blood 1:25,000
West Nile virus 1:50,000
Bacterial contamination 1:1,000,000
Hepatitis C 1:3,000,000
Malaria 1:4,000,000
HIV, AIDS 1:5,000,000
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 Patient reactions CRC:
Fever 1:500
Allergic, minor 1:250
Allergic, major 1:20,000
Volume overload 1:5,000
Acute haemolytic 1:10,000
Delayed haemolytic 1:9,000
Acute lung injury 1:70,000
Post transfusion purpura 1:140,000
Graft
23/10/08
against host 1:1,000,000
72
 Blood component therapy
• Erythrocyte concentrates
• Washed erythrocytes
• Leukocyte concentrates
• Platelet concentrates
• Fresh frozen plasma
• Cryoprecipitate plasma
• Albumin 5%
• Albumin 25%.
• Immunoglobulins
•23/10/08
Coagulation factor concentrates 73
 Erythrocyte transfusion,
indications:
• Haemorrhage, severe anaemia which is not
corrected by other means or needs rapid
correction
• If repeated transfusion are likely then
phenotype cells ABO and Rh which
correspond as closely as possible to the
minor cell antigens of the recipient to
minimize sensitization
23/10/08 74
 Blood substitutes
• Fluorocarbons – Japan.
• Treated haemoglobin. E.g. Haemosol from
MDS (now sold to USA).

• [Of great interest to French elite cyclist in

the Tour de France 2003!]

23/10/08 75
 Procedures to minimise blood
transfusion:
• Autologous (self) donation
• EPO – (self) blood boosting
then autologous transfusion.
• Keyhole, laser surgery.

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 Leukocytes

Robert Moore

23/10/08 78
 Leukocytosis >10 billion/L
1. Physiological –infancy, pregnancy
2. Infection
3. Haemorrhage
4. Trauma
5. Myeloproliferative disease
6. Malignancy
7. Myocardial infarction
8. Drugs
9. Chemicals
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 Leukocytes
• Neutrophils
• Eosinophils
• Basophils
• Monocytes
• Lymphocytes

23/10/08 80
 Neutrophils
• Half in blood,
• Half in reserve,
• Adhesion molecules on surface
• Most numerous
• Lifespan is 10 hours
• Enter tissues by Chemotaxis
• Phagocytosis
• Apoptosis (killing by oxidants and superoxides –
the “respiratory burst”)
23/10/08 81
 Neutrophils: increased
• Infections,
• Pregnancy
• Inflammatory disease
• Trauma
• Malignancy
• Acute haemorrhage
• Metabolic disease
• Myeloproliferative disease
• Drugs
23/10/08 82
 Neutrophils decreased:
under produced, worn out or
pooled
1. Drugs
2. Autoimmune connective tissue
disease
3. Infections
4. Idiopathic

23/10/08 83
 Eosinophils
• Chemotaxis
• Growth factor IL-5
• Engulf large foreign bodies
• Histamine involved
Increased in
• Allergies
• Parasitic infections
• Drugs
• Connective tissue disorders
•23/10/08
Hodgkin’s lymphoma 84
 Basophils (Mast cells in tissues)
• May not function in blood.
• Release histamine following IgE on surface
receptors
Increased in:
• Hypersensitivity
• Myeloproliferative disease: CML
• Inflammatory bowel disease
• Hypothyroidism
• Recovery after acute infections.
23/10/08 85
 Monocytes (macrophages)
• Phagocytic cells that last
• Circulate for 20-40 hours then enter tissues,
remain for days to months
• Long cytoplasmic projections which interact with
other cells
• Present antigens to T-lymphocytes
• Cytokine source e.g. IL-1
• In bone called osteocytes
• In liver called Kuppfer cells
23/10/08 86
 Monocytes
Increased:
• Infections
• Inflammation
• Malignancy

Decreased:
• corticosteroids

23/10/08 87
 Leukaemias
• 10/100,000 population
• Men>women
• Genetic
• Radiation
• Chemotherapy
• Viral infections
• Smoking?
• Environment – power lines
23/10/08 88
23/10/08 89
 Classification of haematological
malignancies:
Acute Chronic
Lymphoid ALL CLL
HL
NHL
Multiple myeloma
Myeloid AML CML
MDS myelodysplasia
Myeloproliferative
23/10/08 90
 Haematological malignancies:
phenotype
Clone of malignant cells

• Apoptosis (death) - decreased

• Proliferation - increased
• Differentiation decreased.

23/10/08 91
Acute myeloid leukaemia (AML)
• Malignant transformation of myeloid precursor
cell into “blast” cells – 30% of bone marrow.
• Incidence increased with age
• Classification: FAB, 8 varieties
• Clinically: some are very ill, some hardly ill.
Acute onset < 3 months, anaemia, abnormal
bruising, Disseminated intravascular coagulation
DIC, skin, bone, gums with hypertrophy.

23/10/08 92
 Acute myeloid leukaemia:
diagnosis
• CBC-anaemia, thrombocytopenia, neutropenia
• Blood smear – Blast cells
• Bone marrow –Blast cells
• Cytochemistry – granules Auer rods
• Immunophenotype –CD33,CD13 etc
• Cytogenetics -karyotypes
• Molecular biology –11q23 etc

23/10/08 93
 Acute myeloid leukaemia:
management
• Chemotherapy
• Bone marrow transplant, if < 50 years
• Supportive care

• 80-90% of young have remission

• Real cure rate is 30%

23/10/08 94
 Acute lymphoblastic leukaemia
(ALL)
• Lymphoid precursor cell clone
• 80% are B lymphocytes
• 20% T lymphocytes
• Childhood illness
• 6 weeks to death
• Male>female

23/10/08 95
 Acute lymphoblastic
leukaemia:classification
• FAB based on appearance: L1, L2, L3
• Immunophenotypes:
Pro-B: CD19,TdT
Common A : CD10,CD19,cytCD22,TdT
Pre B-ALL: cyIg,CD19,cytCD22,TdT
B-ALL: sMIg,CD19,CD20
T-ALL: CD7,cytCD3,TdT
• Antigen measured Cell surface: sMIg
• Morphological analysis: periodic acid Schiff
(PAS)
23/10/08 96
 Acute lymphoblastic leukaemia:
clinical
• Anaemia.
• Infection
• Haemorrhage
• Anorexia
• Back pain
• Raised CNS pressure
• Hepatosplenomegaly
• Testes infiltration perhaps
• Sweating, fever, general malaise
23/10/08 97
ALL: management and prognosis
• Supportive
• Chemotherapy
• Treatment by total body radiation or bone
marrow transplant

• In children, 2 years of treatment, 70% will

survive for 5 years
• In adults 20% will survive
23/10/08 98
 Chronic myeloid leukaemia
(CML)
• Clone of a pluripotential stem cell
• Over production of neutrophils and precursors
• Chronic, accelerated, “Blast crisis”
• 1 in 100,000
• All ages, peak 25-45 years of age
• Well during chronic phase but 80% go to AML
and 20% to ALL. Median survival then is 4 years
• Philadelphia chromosome (t9,22) in 95%

23/10/08 99
 Chronic myeloid leukaemia:
clinical
• Anaemia
• Anorexia
• Weight loss
• Night sweats
• Splenomegaly 90%
• Gout
• Hyperviscosity – priapism, headaches, visual
disturbance

23/10/08 100
 Chronic myeloid leukaemia:
diagnosis
• CBC – raised white cell count
• Blood smear - basophils
• Cytogenetics: Philadelphia chromosome
9,22(q34q11)
• Low leukocyte ALP
• High serum vitamin B12
• High serum uric acid
• Bone marrow hypercellular with raised
myeloid/erythroid ratio.

23/10/08 101
 Chronic myeloid leukaemia:
management
• Chronic: cytotoxic drugs,
hydroxyurea,
alpha interferon,
bone marrow transplants,
tyrosine kinase inhibitor STI 571 under
trial,
Allopurinol to control gout.

• Advanced: bone marrow transplant but results are

poor
23/10/08 102
 Chronic lymphatic leukaemia:
• Clone of B lymphocyte
• Most frequent
• Disease of elderly, peak age 72 years.
• Commonest leukaemia in the West > 70
new cases/million/ year in the UK. Rare in
Asia.
• Male: female is 2:1

23/10/08 103
 Chronic lymphatic leukaemia:
clinical
Mild: Stages A and B, slow and treatable.
Rapid: Stage C, bone marrow fails.
• Lymphadenopathy 60%
• Hepatosplenomegaly 25%
• Skin
• Gastrointestinal
• CNS
• Lungs
• Kidney
• Bone
• Infections and some cancers
23/10/08 104
 Chronic lymphatic leukaemia:
diagnosis
• CBC - lymphocytes 5-500 billion/L,
Anaemia, thrombocytopenia
• Blood smear – “smear” cells (sometimes
“Hairy cell” leukaemia – rare)
• Immunophenotype – B lymphocyte antigens
CD19, CD22, CD5. Surface IgM weak, K
or L
• Serum immunoglobulins are depressed
23/10/08 105
 Chronic lymphatic leukaemia:
management
• Chemotherapy: Chlorambucil for stage B,
combination chemotherapy for stage C
Purine analogues –Fludarabine for
stage C
• Radiotherapy

• No cures
• Chronic usually,10 years or more; does not go to
acute but may flare up.

23/10/08 106
 Acute leukaemias
Acute myeloid leukaemia Acute lymphoid leukaemia
Older age Childhood
Myeloid precursor Lymphoid precursor
Anaemia, leukaemia Anaemia, lymphocytes,
variable, coagulation thrombocytopenia
Bone marrow: blast cells Philadelphia chromosome 10-
30%
LD, urate increased
Variable symptoms
Cure 30%
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 Chronic leukaemias
Chronic myeloid leukaemia Chronic lymphoid
leukaemia
25-40 years Elderly
Neutrophils and precursor cells B lymphocytes
Anaemia, neutrophils, Lymphocytosis
reticulocytes, thrombocytosis
Philadelphia chromosomes
95%
Urate increased Gamma globulin down
Slow/advance to acute Slow/ rapid
Few cures
23/10/08 No cure 108
 Lymphocytes
B lymphocytes –humoral immunity.
Some live for years – memory.
T lymphocytes – triggered by
antigens from macrophages – cell
medicated immunity. 70% in
peripheral blood

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 Lymphocytes: increased
• Infections
• Lymphatic leukaemia CLL, ALL, NHL
• Physiological
• Thyrotoxicosis
• Hypopituitarism
• Some carcinomas
• myasthenia
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 Lymphocytes: decreased
• Inflammation
• Corticosteroids
• Immune deficiency
• Some cancers
• Connective tissue disease

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 lymphocytes
T s te m c e l ls

b u r s a e q u iv a le n t T h ym us

B - ly m p h o c y te T - ly m p h o c y te

p la s m a c y te r e a c t iv e T - ly m p h o c y te

H U M O R A L IM M U N IT Y C E L L M E D IA T E D IM M U N IT Y

23/10/08 113
 Lymphocytes and leukocytes
h e m a t o p o ie t ic s te m c e ll

n o n ly m p h o id s t e m c e ll ly m p h o id s t e m c e ll

e r y t h r o c y te m o n o c y te g r a n u lo c y te th r o m b o c y te T c e ll B c e ll p la s m a c y te

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 B-lymphocytes
• Stimulate change to plasma cells
• Make specific antibodies
• First IgM
• then IgG made

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 T-lymphocytes
• 75% of lymphocytes
• Selected in thymus
• 2/3 helper-T (CD4)
• Recognize antigen and self HLA on presenting
cell
• 1/3 cytotoxic (CD8) bind with antigen and HLA of
target cell
• Interleukin-2 is main T-cell growth factor.
• Suppressor T cells regulate B cells
23/10/08 116
 Immunophenotypic cell markers
• CD3 - mature T
• CD4 – helper T
• CD5 – T and B subset
• CD8 – suppressor T
• CD10 – precursor B (seen in ALL)
• CD14 – monocytes
• CD19 – B
• CD34 – stem cells
• CD56 – natural killer
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 Immune response
• T cells - helper CD4
Suppressor CD8
Cytotoxic CD8 – can lyze antigen
presenting cells APCs
• B cells
• APC – release IL-6, IL-7.
• Plasma cells - immunoglobulins IgG, IgM, IgA,
IgD and IgE.
• Complement – plasma proteins and cell surface
receptors.
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 Natural Killer cells
• Subset of cytotoxic
• Do not need HLA (CD56)
• Kill by adhesion to the target cell or by
antibody dependent cell mediated toxicity

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23/10/08 120
 Hodgkin’s lymphoma.
Lymphoma I, HL
• Male 2:1
• 200 new case/year/million
• Peak incidence15-40 years
• ? After infection with EBV
• Early lymph cells and inflammation
• Over 50 years, due to environment
• Malignant cells are small part of tumour, rest is
inflammation

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 Hodgkin’s lymphoma: clinical
• Enlarged nodes
• Splenomegaly
• Hepatomegaly
• Sweating
• Fever
• Weight loss
• Itching
• Fatigue
• Pain on drinking alcohol
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 Hodgkin’s lymphoma: diagnosis
and staging
• Biopsy of lymph nodes
• CBC
• CT scan
• Lymphangiography
• Laparotomy

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 Hodgkin’s lymphoma
• Management
Early: radiotherapy
Late: chemotherapy
• Prognosis:
Early 85% cure
Late 70% cure
• Secondary malignancy – leukaemia and NHL in
20% in 20 years,
• Sterility.
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 Hodgkin’s L: laboratory work
• Anaemia, normocytic, normochromic
• Leukocytosis, eosinophilia
• Leuko-erythroblastic blood film
• Erythrocyte sedimentation rate ESR
increased
• Serum lactate dehydrogenase LD increased.

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 20 year old man, microcytic
anaemia, fever, night sweats.
CBC: b-Hb 95 g/L (135-170)
MCV 69 fL (80-96)
RDW 26% (9-13)
Platelets 250 billion/L (150-400)
Leukocytes 60 billion/L (4-12)
Bone marrow aspirates: polymorphic cell infiltrate,
many Reed-Sternberg cells.
Cervical lymph node biopsy: sclerosis, Reed-
Sternberg cells.
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 Non-Hodgkin’s lymphoma
(NHL). lymphoma II.
• Common, 4th rank haematology cancer
• Increasing incidence
• Men: women 3:1, any age, median 50 years
• [ex-king Hussein and NHL players with
NHL include Mario Lemieux, S. Koivu]
• Causes: genetics,
viral?
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 NHL: clinical
• Nodal- painless lymphoadenopathy in cervical
region
• Extranodal- abdominal pain, anaemia, dysphagia,
CNS disease, headaches, cranial nerve palsies,
spinal cord compression, pancytopenia
• Systemic – sweating, weight loss, hyperuricaemia,
renal failure, hypercalcuria sometimes.

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 NHL: diagnosis and staging
• Biopsy
• Immunotyping, B or T
• Chromosome studies
• CT or MRI Scanning
• Bone marrow aspirate
• Serum lactate dehydrogenase (LD)

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 NHL: laboratory work
• Similar to HL : anaemia, leukocytosis, blast
blood film, ESR, LD
• Pancytopenia
• Peripheral blood lymphocytosis
• Paraprotein and hypogammaglobulinaemia

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 NHL: management
• Low grade
• High grade:
CHOP 60% remit
Bone Marrow Transplant
Methotrexate
• Cranial irradiation.
• Cure rate 30-40%.
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 The REAL classification
• B-cell neoplasms
• T/NK-cell neoplasms

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 50 year old man, 6 months
history aches, pains, tiredness.
Thirst, , 2 months of night sweats, lost 18 kg in 9
months.
Generalized lymphadenopathy.
• Serum ALP 230 IU/L (<100)
• Wbc 7 billion/L (4-11)
• Hb 110 g/L (130-175)
• Platelets 200 billion/L (150-400)
• Urine protein 15 g/d (0)
• Chest X ray, CT scan of abdomen, lymph node
biopsy.
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 Infectious mononucleosis
• Acute self limiting febrile illness of B
lymphocytes
• Caused by Epstein-Barr virus.
• Young adults 15-21 years of age
• ‘flu, pharyngitis, adenopathy, rash,
petechiae, splenomegaly.
• 2-4 weeks
• No treatment.
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 “Mono” laboratory tests
• CBC: variable with atypical lymphocytes
• Rarely anaemia
• Rarely thrombocytopenia
• High titre of heterophile agglutinins
• Spot (Monospot) or slide tests widely used
but clinical sensitivity is 80%.

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 Lymphomas:
Hodgkin’s
20-30 years, virus?
Lymphoid + inflammation
Nodes, spleen, liver
Pain on drinking alcohol
Anaemia, leuko, eosinophilia
ESR, LD increased
Biopsy:Reed Sternberg cell
Cure 70-80%,second cancer
23/10/08
Non Hodgkin’s (NHL)
median 50 years, virus?
May be CNS,spine,renal
Nodes and beyond
Abdominal pain
Pancytopenia,lympho,hypgl
oLD, urate, calcium increase
Biopsy:B/T lymphocyte
Cure 30-40%,
136
 Myeloma

Malignant disorders
of plasma cells
23/10/08 137
 Myeloma
• Clones of plasma cells in bone marrow
• Fragments of immunoglobulins produced
• Precipitate out in urine as Bence-Jones
proteins.
• [IL-6, IL-beta – lead to osteolysis,
hypercalcaemia and renal failure]
• 10-15% of haematological malignancies

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 Myeloma
• 1% of population over 50 years,
• 50 cases/million.
• 3% if over 70 years
• Decreasing in incidence
• HIV patients have more of it than controls
• Herpes virus may be trigger
• Black:white 2:1
• Men>women
• Median age at dx 71 years
23/10/08 139
 Myeloma: clinical
• Vertebral collapse 80%
• Bone pain, back and chest 67%
• Anaemia 90%
• Hypercalcaemia 45%
• Amyloidosis 45%
• Macroglossia, hepatosplenomegaly, carpal tunnel
syndrome
• Renal failure 45%
• Weakness, fatigue, bleeding, bruising, infections.
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 Myeloma: diagnosis
• Monoclonal protein in serum and/or urine
• Usually light chain
• If heavy chain in serum only
• 1-5% of myelomas do not put out a recognised
protein
• Typing: IgG, IgA, IgM or IgD
Kappa or lambda chain
Fc fragment

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 Myeloma:prognosis
• IgG type - median survival 3 years
90% dead by 10 years
• IgD type - median survival 2 years
80% dead by 5 years

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 Myeloma: paraprotein
• IgG • 70%
• IgA • 20%
• IgM • Uncommon
• IgD • Rare
• IgE • Rare

23/10/08 143
 Myeloma: bad news
• b-Hb decreased
• s-calcium increased
• s-M or u-BJ protein much increased
• Multiple lytic lesions on X ray
• s-creatinine increased
• s-beta-2-microglobulin increased- prognosis
• s-albumin decreased
• s- cryoglobulins
23/10/08 144
 Myeloma: treatment
Delays death by up to 2 years
Radiotherapy
Bisphosphonates – strengthen bone
Thalidomide
Steroids
Analgesics
Renal dialysis
23/10/08 145
 60 year old man. Low back pain,
weight loss.
In pain, pale.
Proteinuria
s-protein 100 g/L (60-80)
s-EPG Monoclonal peak in gamma region.
b-Hb 90 g/L (135-170)
Platelets 60 billion/L (150-400)
ESR 110 mm/h (0-20)
23/10/08 146
 Related disorders
• MGUS – benign monoclonal gammopathy
• Primary amyloidosis
• Solitary plasmacytoma
• Waldenstrom’s macroglobulinaemia
• Plasma cell leukaemia

23/10/08 147
 Mayo clinic 1149 patients
Monoclonal gammopathy of undetermined 63%
significance
Myeloma 14%

Amyloidosis 10%

Lymphoproliferative diseases 3%

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 Myelo/lymphocyte-problems
summary:
• AML – adults – blast cells
• ALL- children, pre B lymph 80%
• CML –young adult, Philadelphia chromosome
95%.
• CLL – adult, B lymphocytes
• Aplastic anaemia – pancytopenia
• Hodgkin’s – nodes, bone marrow mostly
inflammatory cells
• NHL – extranodal more common
• Myeloma – paraprotein by electrophoresis, plasma
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cells
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