Hematology Course: an overview of Clinical Hematology Dr. Ahmed Elshebiny , MD Lecturer of Internal Medicine Faculty of Me...
Course includes <ul><li>Hematology an Overview : The blood and bone marrow </li></ul><ul><li>Clinical Hematology : The ful...
Structure and Function The blood and bone marrow
Blood as a circulatory fluid <ul><li>A protein rich fluid called plasma in which cellular elements are suspended </li></ul...
 
Blood is continuously renewed
The Bone Marrow is the blood Factory May be exposed to damage or failure
Spleen? <ul><li>Blood filter </li></ul><ul><li>Immunity </li></ul>
Red blood cells <ul><li>A nucleated </li></ul><ul><li>Diameter and thickness </li></ul><ul><li>Membrane </li></ul><ul><li>...
Red cell membrane <ul><li>Phospholipid bilayer </li></ul><ul><li>Intracellular protein network </li></ul><ul><li>50%  chol...
Hemoglobin <ul><li>Tetramer of 4 globin chains (proteins) </li></ul><ul><li>Each with a heme group containing iron </li></...
 
Fetal and neonatal hemoglobins
HB and MCV  values with age & sex
Haemopooiesis <ul><li>Yolk sac ( 3 rd week) </li></ul><ul><li>Liver and spleen ( 6 wk to 7 months) </li></ul><ul><li>Bone ...
 
Aplastic Anemia
Bone marrow aspiration and biopsy
Bone marrow aspiration
P.N.H
Hematology Course (2): Clinical Hematology Abnormal Blood count
Manifestations of blood diseases <ul><li>Anemia </li></ul><ul><li>High hemoglobin </li></ul><ul><li>Bleeding </li></ul><ul...
Full blood count <ul><li>Common investigation </li></ul><ul><li>Can point to hematological disorders </li></ul><ul><li>Cor...
N.B. <ul><li>5% of the normal population lie outside the normal range </li></ul><ul><li>Race may affect the CBC </li></ul>...
Anemia <ul><li>Definition </li></ul><ul><li>Morphological approach </li></ul><ul><li>Etiological( kinetic ) approach </li>...
Polycythemia <ul><li>True Polycythemia( Primary and secondary) </li></ul><ul><li>Relative ( decreased plasma volume) </li>...
Leucocytosis <ul><li>Examine the differential count </li></ul><ul><li>Examine a blood film </li></ul><ul><li>Commonest is ...
WBCs <ul><li>5 WBCs line ( diffrential) </li></ul><ul><ul><li>Neutrophils </li></ul></ul><ul><ul><li>Lymphocytes </li></ul...
Neutropenia <ul><li>Clinically evident when ANC < 500 </li></ul><ul><li>Congenital and acquired </li></ul><ul><ul><li>Cong...
Drugs associated with neutropenia <ul><li>Anticonvulsants  ---- phenytoin </li></ul><ul><li>Antithyropid  ------- carbimaz...
Neutrophil disorders <ul><li>Infections( viral, salmonella, protozoal, malaria) </li></ul><ul><li>Drugs </li></ul><ul><li>...
Lymphocytic count disorders <ul><li>Infections( recent viral) </li></ul><ul><li>(immunosuppressive, cortisone) </li></ul><...
Eosinophils <ul><li>Acute inflammation </li></ul><ul><li>Steroids </li></ul><ul><li>Catecholamines </li></ul><ul><li>Aller...
Basophils <ul><li>Hyperthyroidism </li></ul><ul><li>Inflammation ( Acute hypersensitivity, IBD) </li></ul><ul><li>Iron dif...
Monocytosis <ul><li>Viral and fungal infections </li></ul><ul><li>T.B infection </li></ul><ul><li>C.T diseases </li></ul><...
Platelets (thrombocytopenia) <ul><li>Spurious </li></ul><ul><li>Increased consumption </li></ul><ul><li>Decreased producti...
Platelets (thrombocytosis) <ul><li>Reactive </li></ul><ul><li>Primary </li></ul>
Blood film <ul><li>Abnormal shape ( poikilocytosis) </li></ul><ul><li>Spherocytes </li></ul><ul><li>Target cells </li></ul...
Hematology Course (3): Clinical Hematology Anemia :  a clinical approach!
Anemia is operationally defined as a reduction in one or more of the major RBC measurements:  hemoglobin concentration, he...
Kinetic approach to anemias <ul><li>Decreased erythrocyte production  </li></ul><ul><ul><li>Decreased erythropoietin produ...
Normal blood film
Morphological approach
Reticulocytes <ul><li>Increased reticulocytes (greater than 2-3% or 100,000/mm3 total) are seen in blood loss and hemolyti...
Reticulocytes
Low MCV <ul><li>Iron Deficiency </li></ul><ul><li>Thalassemia </li></ul><ul><li>Lead poisoning </li></ul><ul><li>Siderobla...
Iron difficiency anemia Thalassemia
Thalassemia
Sickle cell anemia
Spherocytosis
Hemolytic anemia
Normocytic anemia <ul><li>Causes </li></ul><ul><li>Approach </li></ul><ul><li>Reticulocytic count </li></ul><ul><li>Coomb’...
Macrocytic anemia
B  12  and folate deficiency
References <ul><li>Merck manual : online textbook </li></ul><ul><li>E-medicine , online textbook ,  </li></ul><ul><li>spec...
THANK  YOU
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Hematology (1) The blood and bone marrow, abnormal blood count, anemias: an overview

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Hematology (1) The blood and bone marrow, abnormal blood count, anemias: an overview

  1. 2. Hematology Course: an overview of Clinical Hematology Dr. Ahmed Elshebiny , MD Lecturer of Internal Medicine Faculty of Medicine, Menoufyia University Former Clinical Research Fellow, Joslin Diabetes Center, Harvard University
  2. 3. Course includes <ul><li>Hematology an Overview : The blood and bone marrow </li></ul><ul><li>Clinical Hematology : The full blood count </li></ul><ul><li>Anemia : a Clinical approach </li></ul><ul><li>Deficiency anemias </li></ul><ul><li>Hemolytic anemia : Acquired </li></ul><ul><li>Hemolytic anemia : inherited </li></ul><ul><li>Bone marrow failure syndromes ( aplastic, myeloysplastic, PNH) </li></ul><ul><li>Hypoproliferative anemias (of chronic disease) </li></ul><ul><li>Myeloproliferative disorders </li></ul><ul><li>Leukemias </li></ul><ul><li>Lymphomas & Myelomas </li></ul><ul><li>Porphyria & Hemochromatosis </li></ul><ul><li>Leukocyte disorders </li></ul><ul><li>Interpretation of standard hematologic tests </li></ul>
  3. 4. Structure and Function The blood and bone marrow
  4. 5. Blood as a circulatory fluid <ul><li>A protein rich fluid called plasma in which cellular elements are suspended </li></ul><ul><li>Carrier of O 2 and CO 2 </li></ul><ul><li>Carries nutrients </li></ul><ul><li>Carries waste </li></ul><ul><li>Hormones </li></ul><ul><li>Immunity </li></ul><ul><li>Hemostasis </li></ul>
  5. 7. Blood is continuously renewed
  6. 8. The Bone Marrow is the blood Factory May be exposed to damage or failure
  7. 9. Spleen? <ul><li>Blood filter </li></ul><ul><li>Immunity </li></ul>
  8. 10. Red blood cells <ul><li>A nucleated </li></ul><ul><li>Diameter and thickness </li></ul><ul><li>Membrane </li></ul><ul><li>Metabolism </li></ul>
  9. 11. Red cell membrane <ul><li>Phospholipid bilayer </li></ul><ul><li>Intracellular protein network </li></ul><ul><li>50% cholestrol </li></ul><ul><li>Membrane proteins </li></ul><ul><ul><li>( glycophorin c and band 3) </li></ul></ul><ul><li>Reticuloproteins </li></ul><ul><ul><li>( spectrin , actin, ankyrin) </li></ul></ul>
  10. 12. Hemoglobin <ul><li>Tetramer of 4 globin chains (proteins) </li></ul><ul><li>Each with a heme group containing iron </li></ul><ul><li>Can be distinguished by electrophoresis </li></ul><ul><li>Chain types </li></ul><ul><ul><li>Alpha </li></ul></ul><ul><ul><li>Beta </li></ul></ul><ul><ul><li>Gamma </li></ul></ul><ul><ul><li>Delta </li></ul></ul><ul><ul><li>Zeta and epsilon are embryonic </li></ul></ul>
  11. 14. Fetal and neonatal hemoglobins
  12. 15. HB and MCV values with age & sex
  13. 16. Haemopooiesis <ul><li>Yolk sac ( 3 rd week) </li></ul><ul><li>Liver and spleen ( 6 wk to 7 months) </li></ul><ul><li>Bone marrow </li></ul><ul><li>Red marrow & yellow marrow </li></ul><ul><li>Extramedullary ---- When? </li></ul>
  14. 18. Aplastic Anemia
  15. 19. Bone marrow aspiration and biopsy
  16. 20. Bone marrow aspiration
  17. 21. P.N.H
  18. 22. Hematology Course (2): Clinical Hematology Abnormal Blood count
  19. 23. Manifestations of blood diseases <ul><li>Anemia </li></ul><ul><li>High hemoglobin </li></ul><ul><li>Bleeding </li></ul><ul><li>Thrombosis </li></ul><ul><li>Infections </li></ul><ul><li>Lymphadenopathy </li></ul><ul><li>Splenomegaly </li></ul>
  20. 24. Full blood count <ul><li>Common investigation </li></ul><ul><li>Can point to hematological disorders </li></ul><ul><li>Cornerstone of hematological diagnosis </li></ul><ul><li>Manual or automated </li></ul><ul><li>Automated counting and sizing by different methods e.g. ( Aperture impedance) </li></ul><ul><li>They also measure the hemoglobin by spectrophotometry </li></ul><ul><li>Some other parameters are calculated ( MCH, MCHC) </li></ul><ul><li>The automated analyzers can diffrentiate leukocyte </li></ul>
  21. 25. N.B. <ul><li>5% of the normal population lie outside the normal range </li></ul><ul><li>Race may affect the CBC </li></ul><ul><li>Be careful of artifacts </li></ul>
  22. 26. Anemia <ul><li>Definition </li></ul><ul><li>Morphological approach </li></ul><ul><li>Etiological( kinetic ) approach </li></ul><ul><li>RBCs in the blood film </li></ul>
  23. 27. Polycythemia <ul><li>True Polycythemia( Primary and secondary) </li></ul><ul><li>Relative ( decreased plasma volume) </li></ul>
  24. 28. Leucocytosis <ul><li>Examine the differential count </li></ul><ul><li>Examine a blood film </li></ul><ul><li>Commonest is neutrophilia </li></ul>
  25. 29. WBCs <ul><li>5 WBCs line ( diffrential) </li></ul><ul><ul><li>Neutrophils </li></ul></ul><ul><ul><li>Lymphocytes </li></ul></ul><ul><ul><li>Monocytes </li></ul></ul><ul><ul><li>Eosinophils </li></ul></ul><ul><ul><li>Basophils </li></ul></ul>
  26. 30. Neutropenia <ul><li>Clinically evident when ANC < 500 </li></ul><ul><li>Congenital and acquired </li></ul><ul><ul><li>Congenital ( e.g Kostman;s syndrome and cyclic neutropenias) </li></ul></ul><ul><ul><li>Most cause of acquired neutropenia is drugs </li></ul></ul>
  27. 31. Drugs associated with neutropenia <ul><li>Anticonvulsants ---- phenytoin </li></ul><ul><li>Antithyropid ------- carbimazole </li></ul><ul><li>Phenothiazines ------ carbamazepine </li></ul><ul><li>Antibacterial -------- phenylbutazone </li></ul><ul><li>Anti-inflammatory ------ co trimoxazole </li></ul><ul><li>Cytotoxic </li></ul><ul><li>Others ----- gold, penicillamine, imipramine </li></ul>
  28. 32. Neutrophil disorders <ul><li>Infections( viral, salmonella, protozoal, malaria) </li></ul><ul><li>Drugs </li></ul><ul><li>Autoimmune </li></ul><ul><li>Alcohol </li></ul><ul><li>Congenital </li></ul><ul><li>Infections ( bact, fungal) </li></ul><ul><li>Surgery, Burns </li></ul><ul><li>Infarctions </li></ul><ul><li>Inflammation ( gout, RA, IBD) </li></ul><ul><li>Malignancy (CML) </li></ul><ul><li>Physiological </li></ul>Neutroppenia Netrophilia
  29. 33. Lymphocytic count disorders <ul><li>Infections( recent viral) </li></ul><ul><li>(immunosuppressive, cortisone) </li></ul><ul><li>Autoimmune & CT diseases </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Chronic renal failure </li></ul><ul><li>Congenital : severe combined immunodifficiency </li></ul><ul><li>Infections ( viral, pertussis, glandular fever) </li></ul><ul><li>Lymphoproliferative ( CLL, lymphoma ) </li></ul><ul><li>Post splenectomy </li></ul>Lymphopenia Lymphocytosis
  30. 34. Eosinophils <ul><li>Acute inflammation </li></ul><ul><li>Steroids </li></ul><ul><li>Catecholamines </li></ul><ul><li>Allergy ( asthma, eczema) </li></ul><ul><li>Infections ( Helminths, viral) </li></ul><ul><li>Skin disease </li></ul><ul><li>C.T disease e.g PAN </li></ul><ul><li>Malignancy ( solid tumors and lymphomas) </li></ul><ul><li>Gold therapy </li></ul>Eosinopenia Eosinophilia
  31. 35. Basophils <ul><li>Hyperthyroidism </li></ul><ul><li>Inflammation ( Acute hypersensitivity, IBD) </li></ul><ul><li>Iron difficiency </li></ul><ul><li>Myeloproliferative disorders ( Polythycemia, CML) </li></ul>basopenia Basophilia ( rare)
  32. 36. Monocytosis <ul><li>Viral and fungal infections </li></ul><ul><li>T.B infection </li></ul><ul><li>C.T diseases </li></ul><ul><li>Inflammatory bowl disease </li></ul><ul><li>Myeloproliferative </li></ul><ul><li>Chronic Myelomonocytic leukemia ( one of MDS) </li></ul><ul><li>Malignancy e.g solid tumors </li></ul>
  33. 37. Platelets (thrombocytopenia) <ul><li>Spurious </li></ul><ul><li>Increased consumption </li></ul><ul><li>Decreased production </li></ul>
  34. 38. Platelets (thrombocytosis) <ul><li>Reactive </li></ul><ul><li>Primary </li></ul>
  35. 39. Blood film <ul><li>Abnormal shape ( poikilocytosis) </li></ul><ul><li>Spherocytes </li></ul><ul><li>Target cells </li></ul><ul><li>Polychromasia </li></ul><ul><li>Dimorphic film </li></ul><ul><li>Lobulation and toxic granulation </li></ul><ul><li>A typical cells </li></ul><ul><li>Blast cells </li></ul><ul><li>Malaria </li></ul><ul><li>others </li></ul>
  36. 40. Hematology Course (3): Clinical Hematology Anemia : a clinical approach!
  37. 41. Anemia is operationally defined as a reduction in one or more of the major RBC measurements: hemoglobin concentration, hematocrit, or RBC count Keep in mind these are all concentration measures … most accurately measured by obtaining a RBC mass via isotopic dilution methods. Definition:
  38. 42. Kinetic approach to anemias <ul><li>Decreased erythrocyte production </li></ul><ul><ul><li>Decreased erythropoietin production </li></ul></ul><ul><ul><li>Inadequate marrow response to erythropoietin </li></ul></ul><ul><li>Erythrocyte loss </li></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Hemolysis </li></ul></ul>
  39. 43. Normal blood film
  40. 44. Morphological approach
  41. 45. Reticulocytes <ul><li>Increased reticulocytes (greater than 2-3% or 100,000/mm3 total) are seen in blood loss and hemolytic processes, although up to 25% of hemolytic anemias will present with a normal reticulocyte count due to immune destruction of red cell precursors. </li></ul><ul><li>Retic counts are most helpful if extremely low (<0.1%) or greater than 3% (100,000/mm3 total). </li></ul>
  42. 46. Reticulocytes
  43. 47. Low MCV <ul><li>Iron Deficiency </li></ul><ul><li>Thalassemia </li></ul><ul><li>Lead poisoning </li></ul><ul><li>Sideroblastic Anemia </li></ul><ul><li>Anemia of chronic disease </li></ul>
  44. 48. Iron difficiency anemia Thalassemia
  45. 49. Thalassemia
  46. 50. Sickle cell anemia
  47. 51. Spherocytosis
  48. 52. Hemolytic anemia
  49. 53. Normocytic anemia <ul><li>Causes </li></ul><ul><li>Approach </li></ul><ul><li>Reticulocytic count </li></ul><ul><li>Coomb’s test </li></ul>
  50. 54. Macrocytic anemia
  51. 55. B 12 and folate deficiency
  52. 56. References <ul><li>Merck manual : online textbook </li></ul><ul><li>E-medicine , online textbook , </li></ul><ul><li>specialties,. </li></ul><ul><li>Bethesda Handbook of Clinical Hematology </li></ul><ul><li>Problem solving in Hematology </li></ul><ul><li>Essential Revisoin notes for MRCP 2009 </li></ul><ul><li>Kumar & Klark : Clinical Medicine 2009 </li></ul><ul><li>Davidson’s : Clinical and practice of Medicine 1999 </li></ul><ul><li>Ganong’s physiology 2010 </li></ul><ul><li>Other Web Resources & books </li></ul>
  53. 57. THANK YOU

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