Internal medicine 2: Blood by Medicos 143

Section 5. HEMATOPOIETIC SYSTEM DISEASES

Introduction 1.

Iron deficiency anemia

Aplastic anemia

Warm antibody autoimmune hemolytic anemia

Myelodysplastic syndrome

Leukemia

Lymphoma

Plasma cell disease

Thrombocytopenia Purpura

INTRODUCTION AND ANEMIA OVERVIEW: To master 1. To master the basic concepts of anemia, the importance for of identifying the cause of anemia, the diagnostic steps and methods;

2. To master the pathogenesis, classification and treatment principles. ERYTHROID LINEAGE  Primitive erythroid precursors (arising from myeloid stem cells)  CFU-E erythroid cells (express receptor for EPO, response to low anemia)  EPO (erythropoietin) : up regulates proliferation of CFU-E cells and promotes their maturation into proerythroblasts and reticulocytes, which begin to synthesize hemoglobin  Reticulocyte, immature red blood cells, a reflection of hematopoietic function of bone marrow erythroid system

STIMULATING FACTORS  Androgens : o Promote the secretion of EPO o Stimulate red bone marrow hematopoietic cell proliferation directly ↑2, 3-DPG

NORMAL RBCs: Structure & function  Deliver oxygen to all the tissues & carry CO2 back from lungs  Have biconcave shape: to maximize the membrane surface gas exchange  Mature red cells  No nucleus  Normal red cells c/a normochromic

ANEMIA  The reduction in the mass of circulating red blood cells：the oxygen binding capacity of the blood is diminished   Erythrocyte production: nutritional deficiency, primary hematologic disease, systemic illness  ↑ Blood loss, cellular destruction from hemolysis  It’s not a diagnosis, it’s a sign of presence of disease  Correct diagnosis: include underlying cause of anemia  1st step: detect the presence of anemia by testing Hb, RBC, Hct  2nd step (Most crucial): find the reason

ANEMIA RANGE RANGE Hemoglobin

RBC

Women: 12 – 16 g/Dl (< 125 g/L)

Mild: >90  Moderate 60-90

Men: 13.5 – 17.5 g/dL (< 110 g/L)

 Severe 30-60  Very severe <30

Women: < 4.0 x 1012 /L Men: < 3.5 x 1012 /L

Deficiency of erythroblast causes: Aplastic anemia PATHOGENIC CLASSIFICATION: imp 

Blood loss: acute hemorrhage, chronic hemorrhage



Hemolysis (destruction): Intracorpuscular, Extracorpuscular



Inadequate production of RBC: Deficiency of essential substance, Deficiency of erythroblast, Abnormal infiltration of bone marrow

MORPHOLOGIC CLASSIFICATION : imp  MCV: Mean Corpuscular Volume  MCH: Mean Corpuscular Hemoglobin  MCHC: Mean Corpuscular Hemoglobin Concentration MCV  MCHC 

Iron Deficiency Anemia

MCV ↑

Megaloblastic Anemia, Lack of Vitamin B12 & folic acid

MCV, MCHC (normal)

Aplastic Anemia, Hemolytic Anemia, Recent blood loss, Infiltrated bone marrow

CLINICAL MANIFESTATION  Resting CO likely to rise, with ↑ in both stroke volume & heart rate , when Hb conc fall below 75 g/L  Compromised myocardial reverse develop cardiac failure  Beyond cardiac or circulatory system, experiences dizziness, headache, syncope, tinnitus or vertigo

CHRONIC BLOOD LOSS  It is usually due to lesions in the gastrointestinal tract or the uterus  Testing of stool for occult blood is an essential but frequently overlooked part of the evaluation of anemia.  If necessary, need to do endoscopy & colonoscopy

PHYSICAL FINDINGS  Pallor is the most evidence sign in patient with anemia  May be suspected by the color of the palms or of non cutaneous tissues such as oral mucous membranes, nail beds, and palpebral conjunctivas  Heart murmurs are common sign, a systolic ejection murmur is often heard over the precordium, particularly at the pulmonic area  A venous hum may be detected over the neck vessels.

RETICULOCYTE COUNT  The reticulocyte count in normal individuals is about 1%, 50,000/mm3.

EXAMINATION OF BLOOD SMEARS  Stomatocytes  Elliptocyte  Dacryocyte  Spherocyte  Acanthocyte  Target cell  Rouleaux formation

ATTENTION  Hb and RBC are affected by changes in the plasma volume: o Plasma volume decreased （HCT ↑）: increased haemoglobin concentration (Dehydration, protracted diarrhoea) o Plasma volume expanded(HCT ); decreased haemoglobin concentration (overhydration hydremia of pregnancy)

TREATMENT  The principle: Pathogenic therapy.  Drug o Iron: Iron deficiency anemia o Glucocorticoid Prednisone: Immune hemolytic anemia, Acute aplastic anemia o Testosterone: Aplastic anemia  Blood transfusion: Acute severe blood loss, CVS collapse  Splenectomy: Hereditary spherocytosis  Bone marrow transplantation: Acute aplastic anemia

CHAPTER 1. IRON DEFICIENCY ANEMIA: To master 1. To master the cause for of iron deficiency, the symptoms and the lab tests;

2. To master the diagnosis and treatment; ERYTHROPOIESIS 

Stem cell  Proerythroblasts  Early erythroblasts  Intermediate  Late  Reticulocytes



Erythropoietin: Hormone to stimulate RBC production

DECREASE OF RBC & HB  Anemia: When RBC and HB of individual is lower than the referential values of the people in same age, same sex & same area. Usually, if Hb of adult male and female is < 120g/L or 110g/L respectively, they are considered anemic

ANEMIA 

Normal range of hemoglobin content of blood is from 120g/L-165g/L for male and from 110g/L-155g/L for female.

ACCORDING TO THE LEVEL OF HB, ANEMIA IS DIVIDED INTO 4 DEGREES IN CLINIC 

Mild anemia

: Hb < 120 g/L (male) or < 110 g/L (female)



Medium anemia

: Hb < 90 g/L



Severe anemia

: Hb < 60 g/L



Extreme severe anemia : Hb < 30 g/L

PATHOLOGICAL ANEMIA   in synthesis of red blood cell in bone marrow  ↑ destroy of red blood cell in peripheral blood  Blood loss

IRON DEFICIENCY ANEMIA (IDA) 

Hypochromic cells in the peripheral blood



MCH , MCV , MCHC reduced



failure of hemoglobin synthesis

CAUSE OF IRON DEFICIENCY : imp  Transfer to fetus: Pregnancy  Haemosiderinuria: Chronic intravascular haemolysis, Paroxysmal nocturnal haemoglobinuria, Heart valve haemolysis  Malabsorption: Atrophic gastritis, Gluten-induced enteropathy, Partial gastrectomy  Poor diet: Poor quality diet  Fall in serum iron & serum ferritin  Rise in total iron binding capacity

IRON DEFICIENCY ANEMIA  Angular cheilosis; atrophic glossitis  Plummer Vinson syndrome  Retinal haemorrhage  Pallor of the mucous membrane  Nail frequently are ridged & brittle  Koilonychia  Angular cheilosis  Atrophic glossitis

BLOOD & BONE MARROW APPEARANCE  Blood film: Hypochromatic microcytic Red cells  Fall in MCH & MCV  Platelet count is often raised

IRON DEFICIENCY  Smear Characteristics: Hypochromia (pale area expand), Microcytosis

CHAPTER 2. APLASTIC ANEMIA: BONE MARROW FAILURE To master To master of the etiology, clinical manifestations and hematological characteristics, diagnosis, differential diagnosis and treatment;

 Aplastic anemia patients have decreased amounts of : o Red Blood Cells o White Blood Cells o Platelets

ETIOLOGY  Inherited: Fanconi’s anemia, Dyskeratosis congenital, Schwacman- Diamond syndrome  Acquired: o Idiopathic o Secondary Causes of Acquired Aplastic Anemia  Chemical Agents: Benzene, insecticides, arsenic, weed killers  Drugs: Chloramphenicol (Anti-biotics), Anticonvulsants, Sulfanomides, Chemotherapy drugs  Ionizing Radiation: Radiation, Gamma rays, X-rays  Infections: Epstein-Barr, Cytomegalo-virus, HIV, Hepatitis, TB, Dengue fever  Miscellaneous Causes: Pregnancy, Gaft-versus-host disease

SYMPTOMS  Low RBC

: Fatigue, weakness

 Low WBC

: Fever, Mouth ulcer

 Low Platelets : Ecchymosis, Bleeding gums, Epistaxis DIAGNOSIS PERIPHERAL BLOOD

BONE MARROW BIOPSY

Pancytopenia

Few hematopoietic cells

Normocytic-normochromic anemia

Empty fatty spaces

Low reticulocyte index (<1%)

More lymphocytes & plasma cells

PERIPHERAL BLOOD: Criteria 

Neutrophils < 500/ μL



Platelets < 20,000/ Ul



Reticulocyte index < 0.5%

TREATMENT  Androgens  Immunosuppression: Cyclosporine A, CsA (orally), Glucocorticoids (congenital pure red cell aplasia), ALT/ATG  Removal of cause (secondary)  Supportive care: RBC, platelets transfusions, cytokines(EPO & G-CSF), Infection, Asepsis  Bone marrow transplant (SCT): Availability of HLA-identical sibling marrow donor

Aplastic Anemia 

Age: Younger the better



BMT: < 20  75% as the age increases the chances decreases. Immunosuppression: 60-80%

CONGENITAL APLASTIC ANEMIA (Fanconi’s Anemia) 

Is autosomal recessive



Have variety of physical abnormalities: Malformed thumbs, Brown skins, Renal abnormalities, Mental retardation, Poor growth



Have pancytopenia, progressively worse as patient ages

PURE RED CELL APLASIA  Only anemia WITHOUT other associated cytopenia  Normal cellularity with absence of erythroid precursor cells

KEY POINTS 

Severe aplastic anemia is a lethal disease



Pancytopenia accompanied by a markedly hypocellular marrow are major evidences for diagnosis of aplastic anemia.



Marrow biopsy is essential to confirm it



Most of aplastic anemia are idiopathic.



Immunosuppression agents can induce good response in aplastic anemia.



Hematopoietic stem cell transplantation is another option for curing the disease.

CHAPTER 4. MYELODYSPLASTIC SYNDROME: MEGALOBLASTIC ANAEMIA To master To master the classification, lab examination and special tests for primary myelodysplastic syndrome;



Fault in DNA synthesis



Deficiency of Vitamin B12 or folate acid

CLINICAL FEATURES (imp)  insidious onset  jaundice  rise in serum lactate dehydrogenase  pancytopenia , bruising  glossitis , angular cheilosis  melanin pigmentation of skin  neuropathy

BONE MARROW APPEARANCE  hypercellular  erythroid ratio may be reversed  asynchrony of nuclear and cytoplasmic maturation  abnormally shaped metamyelocytes  MEGAKARYOCYTES  iron deficiency and megaloblastic anaemia coexist : dimorphic anaemia  Megaloblastic changes may be masked  excessive iron granulation of erythroblasts,  accumulation of early cells and excess mitoses

CAUSES OF MEGALOBLASTIC ANEMIA  B12 deficiency : Daily requirement 1-2mg, Peripheral neuropathy, Addisonian pernicious anemia, early greying of hair, vitiligo, thyroid disorders, gastric atrophy, Small intestinal causes  Folate deficiency: MC cause of deficiency in preqnancy Inadequate dietary intake, malabsorption, tropical sprue, Dermatitis herpetiformis TREATMENT: IM or SC hydroxocobalamin. Oral folic acid

CHAPTER 5. LEUKEMIA: To master To master the classification, symptoms, lab examination, diagnosis and treatment principles; to understand the modern understanding of the etiology, pathogenesis, the incidence and prognosis.

LEUKEMIA  is a malignant disease characterized by unregulated proliferation of one cell type.(one clone of Immature cell)  A disease where the neoplasm inside the bone marrow fills up with abnormal WBC, so no other cells can be synthesized

ETIOLOGY: List of factors that increase your risk in acquiring leukemia  Radiation exposure: o AML, CML are increased in incidence given for  Radiation therapy for ankylosing spondylitis o Survivors of atomic bomb blasts at Hiroshima & Nagasaki  Chemical & drug: o Benzene (eg:kerosene, carbon tetrachloride)  marrow damage, aplastic anemia, myelodysplasia or AML o Alkylating agents (melphalan, nitrosoureas)  risk of AML  Virus: HTVL-I, HTVL-II  Genetics: Down syndrome, Trisomy 13, Mutation at 21q22, Bloom syndrome, Fanconi’s anemia  From other blood disorders: MPD, MDS, PNH, Lymphoma, Myeloma

PATHOPHYSIOLOGY 

Side effects: Fever, Sweats



Because the WBC’s are secreting cytokines (IL-1)

CLASSIFICATION 

Chronic: More mature cells involved



Acute: Poorly diffentiated with many blasts



FAB (French-American-British) Classification o AML  8 subtypes (M0 to M7) based on the type of cell from which the leukemia developed & degree of maturity o ALL  3 subtypes (L1, L2, L3)



WHO Classification  BEST

FAB Classification

AML (Acute Myelogenous Leukemia) o M0: Minimally differentiated leukemia

ALL (Acute Lymphoblastic Leukemia) o L1: MC in children

o M1: Myeloblastic leukemia without maturation

Small with fine or clumped homogenous nuclear

o M2: Myeloblastic leukemia with maturation

chromatin & absent or indistinct nucleoli

o M3: Promyelocytic leukemia

o L2: Frequent Found in adults

o M4Eo: Variant: Increase in abnormal marrow eosinophils

Large cell size, Variable nuclear chromatin

o M4: Myelomonocytic leukemia

& prominent nucleoli

o M5: Monocytic leukemia

o L3: Rarest form

o M6: Erythroleukemia (DiGuglielmo's disease) o M7: Megakaryoblastic leukemia

WHO CLASSIFICATION AML o With certain cytogenetic abnormalities: t(8;21)  chromosome 11 changes, t(15;17) AML M3 o With multi-lineage dysplasia o AML & myelodysplastic syndrome, therapy o Not categorized o Acute leukemia of ambiguous lineage: Undifferentiated or biphenotypic acute leukemia

LEUKEMIA : CLINICAL MANIFESTATION  Anemia  Immunodeficiency  Inhibition of hemostasis  Organ infiltration  Metabolic effects

ANEMIA : CLINICAL MANIFESTATION  Shortness of breath  Pallor  Feeling cold  Dizzy  Irritable  May have headache

CLINICAL MANIFESTATION  Immunodeficiency  Hemostasis : Nose bleeding, Bruising, Petechiae  Organ infiltration : Bone pain, Hepatosplenomegaly, Lymphadenopathy, Gingival hypertrophy, Leukemic meningitis  Metabolic effects : Weight loss, fever, hyperkalemia, hyperuricemia

PHYSICAL FINDINGS • Gingival involvement (especially in the monocytic variants (M4 or M5) ) • Hepatosplenomegaly and lymphadenectasis • Pallor, petechiae, ecchymoses • Bone tenderness（sternum） • Retinal hemorrhage (blindness) • CNS infiltration (more common inALL, M4 and M5) • Skin, soft tissue infiltration.

CHARACTERS OF CYTOCHEMISTRY IN AL  Myloperoxidase (MPO) is strongly POSTIVE  AML NEGATIVE  ALL  Periodic Acid Schiff (PAS) is strongly POSITIVE  ALL

LABORATORY FINDINGS  Peripheral blood  Classification of the immature cells involved o Myeloid maturation sequence o AML maturation sequence o AML o Auer rods in AML o Myeloblasts  auer rods : splinter shaped incusion due to a rod shaped alignment of primary granulas found in myeloproliferative processes o AML M3 (Promyelocytic) o AML M4 eos o ALL  No auer rods

CASE 1  CC（clinical course）: 5YOF presents with fever, marked weakness, pallor, bone pain, and bleeding from her nose  HPI: progressively increasing fatigability and infections over the past few months  PE: marked pallor; epistaxis; ecchymotic patches over skin; sternal tenderness; slight hepatosplenomegaly with non tender lymphadenopathy; no signs of meningitis; normal funduscopic exam.

Gross Pathology  Neoplastic infiltration of lymph nodes, spleen, liver and bone marrow.  Loss of normal bone marrow architecture.

Micro Pathology  Myelophthisic bone marrow (distorted architecture secondary to a space-occupying lesion) with lymphoblastic infiltration  Lymphoblasts with inconspicuous nucleoli, condensed chromatin, scant cytoplasm

Labs  Normocytic, normochromic anemia  Absolute lymphocytosis with excess blasts (>30%)  Negative monospot test for Epstein-Barr virus.  Positive terminal deoxytransferase (TdT)(marker for immature T and B lymphocytes)  Positive CD10 marker (CALLA-Common Acute Lymphoblastic Leukemia Antigen) Diagnosis : Acute Lymphocytic Leukemia (ALL) • Previously >30% blasts on BM aspirate (per FAB criteria) • Recently changed to > 20% blasts on BM aspirate (per WHO criteria)

AML: RESPONSE TO INDUCTION Complete remission: •

Normal peripheral blood counts

•

Normocellular marrow with < 5% blasts and normal marrow cell maturation

TREATMENT IN REFRACTORY OR RELAPSED AML Relapse is defined by > 5 % blasts in bone marrow -

Salvage therapy, Allogenic transplant, Gentuzumab

CASE 2 A 30-year-old nulliparous female suffered from placental abruption at the 25th week of pregnancy, and emergent cesarean section was done immediately with termination of the pregnancy. Labs were significant for a prolonged PTT/INR, anemia, thrombocytopenia. Bone marrow as shown  What is the likely diagnosis?

AML-M3 (APL) an important FAB subtype • Acute Promyelocytic Leukemia (M3) • Blasts and promyelocytes heavily granulated, Auer rods often abundant & DIC (disseminated intravascular coagulation) is common • Treatment differs from all other AML subtypes. (Differentiating agent therapy) • Favorable prognosis (>85% survival)

TREATMENT OF M3  Chemotx. Eg: anthracyclines (idarubicin)  Arsenic trioxide in those that relapse

ALL Treatment: Maintenance  Rationale: Antimetabolite drugs  Periodic intrathecal chemotherapy

TREATMENT: Prophylactic antibiotics: Fluconazole, Acyclovir

CHRONIC MYELOID LEUKEMIA  Overproduction of cells of the granulocytic, especially the neutrophilic series and occasionally the monocytic series, leading to marked splenomegaly and very high white blood cell (WBC) counts.  Basophilia and thrombocytosis are common.

3 CLINICAL PHASES: Initial chronic phase  Accelerated phase  Blast crisis

THE PHILADELPHIA CHROMOSOME Shown is the result of the reciprocal translocation of 22q to the lower arm of 9 and 9q (c-abl to a specific breakpoint cluster region [bcr] of chromosome 22 .

CHRONIC LYMPHOCYTIC LEUKEMIA WHAT ARE THE TYPES OF CLL?  B cell  More common, Makes antibodies to fight bacteria  T cell  Less common, Kill viruses & foreign cell & trigger B cells to make antibodies

TREATMENT  Alkylating agents : Chlorambucil, Cyclophosphamide  Nucleoside analogs : Cladribine, fludarabine  Biological response modifers  Monoclonal antibodies  Bone marrow transplantation  Systemic complications requiring therapy: Antibiotics, Immunoglobulin, Steroids, Blood products

CHAPTER 6. LYMPHOMA: To master To master the classification, diagnosis, stages;

LYMPHOMA: Neoplasm of lymphoid origin, typically causing lymphadenopathy.

WHO CLASSIFICATION OF LYMPHOMA (2016) i. Precursor lymphoid neoplasms ii. Mature B-cell lymphoid neoplasms iii. Mature T & NK-cell neoplasms iv. Hodgkin Lymphoma v. Post-transplant lymphoproliferative disorders, PTLD vi. Histiocytic & dendritic cell neoplasms

CLINICAL DIFFERENCES BETWEEN HODGKIN & NON-HODGKIN LYMPHOMA HODGKIN LYMPHOMA

NON-HODGKIN LYMPHOMA

- Localization to single axial group of nodes

- Involvement of multiple peripheral nodes

(cervical, mediastinal, para-aortic) - Orderly spread by contiguity

- Non-contiguous spread

- Mesenteric nodes, Waldeyer ring: rarely involved

- Mesenteric nodes, Waldeyer ring: commonly involved

- Extranodal involvement

- Curable, Treatable

- Generally not curable, Treatment is asymptomatic

NON HODGKIN LYMPHOMA  50% age (20-40)  Male > Female  NHL 90% > HD 10%  Systemic manifestation o Fever o Night sweats o Weight loss  Local manifestation o Lymphadenopathy, splenomegaly  Most common  Laboratory findings o Flow cytometry. Immunophenotyping of biopsy material is important in NHL

o Immunological tests  M protein (+)  Coomb’s test (+)  Hypoglobulinemia o Other findings  ESR ↑  LDH ↑ o Chromosome changes in NHL t (14; 18)

Follicular lymphoma  bcl-2

t (8; 14)

Burkitt’s lymphoma

t (11; 14)

Mantle-cell lymphoma

t (2; 5)

Ki-1+ (CD30+) Anaplastic large-cell lymphoma

3q27

Diffuse large B-cell lymphoma

o Diagnosis depends on biopsy of lymph nodes or other involved organs

DIFFERENTIAL DIAGNOSIS : Lymph nodes enlargement  Infection

 Reactive

 Malignancies

 Fever

 Connective tissue disease

 Malignancies in related organs

 Sarcoidosis

Three most common lymphomas • Follicular lymphoma • Diffuse large B-cell lymphoma  MC type of aggressive lymphoma • Hodgkin lymphoma

FOLLICULAR LYMPHOMA  Most common type of “indolent” lymphoma  Presentation: Widespread  Asymptomatic  Not curable  Bcl-2 gene; [t(14;18)]  Cell of origin: Germinal center B-cell