INTRODUCTION TO COAGULATION AND Hemorrhage- escape of blood from the blood

HEMOSTASIS
vessels to the external environment
Hemostasis- arrest of bleeding
Mechanisms:
1. Physiologic function
a. Vasoconstriction
b. platelet activation
- adhesion
- aggregation
- release reaction/secretion
c. coagulation
- alpha/dense granules enhance the
process
- fibrinogen is activated and
converted to fibrin which then binds
with the aggregated platelets
forming a solid stable platelet-fibrin
plug
2. surgical procedure
Factors:

Manifestations:
1. purpura
- escape of blood to small areas of tissues
and mucous membrane
heme> biliverdin carried by albumin>
bilirubin
red> purple> brown
2. ecchymosis
- escape of blood to large areas but not deep
to the tissues
- bruise
3. petechiae
- small pin point reddish hemorrhagic spots
that are approximately <3mm in size
- results from the leakage of RBC from
capillaries due to the inability of the
capillaries to withstand pressure or trauma
*typhoid, dengue hemorrhagic fever,
allergies

1. type of surrounding tissue

eg. Thighs- surrounded by skeletal muscle
tissue
Head- no much supporting tissue

4. hemoptysis
- expectoration of blood
*injuries in the upper respiratory tract
(larynx, pharynx, lungs), tuberculosis

2. integrity of blood vessels

- age
- pathologic mechanisms
eg. Dengue hemorrhagic anemia
- megakaryocytes are killed
- decrease in platelets
- platelets and endothelial spaces are
coated by the virus and recognized
as foreign by the immune system

5. epistaxis
- nosebleed
- due to uncontrolled temperature of the
mucous membrane

3. quantity and quality of platelets

7. melena
- blood in stool
- indicates if occult blood test is necessary
a. black-red/black- upper GIT
b. fresh red- lower GIT
*colon cancer

4. presence of coagulation and inhibitory

proteins
eg. Fibrinogen- alpha 2 macroglobulin

6. hematemesis
- vomiting of blood
*colon cancer, abdominal ulcer, upper
gastrointestinal tract infection

8. hemarthrosis
- leakage of blood into joint cavities
- precipitation of blood in conjuction with
uric acid crystals injuring joint cartilages
leading to sepsis
*arthritis

1940s
o Routine tests
o Platelet count
o Clotting time, whole blood clotting
time
o Bleeding time
o Prothrombin time

9. menorrhagia
- excessive uterine bleeding during regular Now
menstrual cycle
HISTORY OF HEMOSTASIS
Background:
2nd century: Aristotle and Plato
o recognized bleeding as the earliest or the 1st
coagulation disorder
5th century: Talmud
o a writing that explained the death of 2 boys
due to bleeding after circumcision

o Activated Partial Thromboplastin

Time
- use of reagents
o Photooptical Readers/Mechanical
Readers
- correlates turbidity to clot
formation
- measure absorbance
o Immunoassays
- radioimmunoassay
- detects fibrinolysis

1803: Otto
o published writings about families with
bleeding disorders
Schnlein
o coined the term hemophilia meaning love
or affinity for blood
1828: Hopff
o published a thesis that described hemophilia
as familial
Development:
1913
o 1st test for coagulation
o Lee & White Whole Blood Clotting
Time/ Clotting Time Tube Method
- manual tilt method
1930: Quick
o Prothrombin Time Test
o Use of reagents to accelerate clot formation

PREFIXES
a/an

Lack, without, absent,

decreased
Aniso
Unequal, dissimilar
Cyto
Cell
Dys
Abnormal, difficult, bad
Erythro
Red
Ferr
Iron
Hemo/hemato
Pertaining to blood
Hypo
Beneath, under, deficient,
decreased
Hyper
Above, beyond, extreme
Iso
Equal, alike, same
Leuk/leuko
White
Macro
Large, long
Mega
Large, giant
Meta
After, next, change
Micro
Small
Myel/myelo
From the bone marrow,
spinal cord
Pan
All, overall, all-inclusive
Phleb
Vein
Phago
Eat, digest
Poikilo
Varied, irregular
Poly
Many
Schis
Split
Scler
Hard
Splen
Spleen
Thromb/thrombo Clot, thrombus
Xanth
Yellow

SUFFIXES
cyte
Emia
itis
Lysis
Oma
Opathy
osis
Penia
Philic
Plasia/plastic
Poiesis
Poietin

Cell
Blood
Inflammation
Destruction, dissolving
Swelling, tumor
disease
Abnormal increase, disease
Deficiency, decreased
Attracted to, affinity for
Cell production or repair
Cell production, formation,
and development
Stimulates production

TERMINOLOGIES
Erythropoiesis

RBC production form

bone marrow
Erythrocytosis
Abnormal increase in
RBC
Anemia
Abnormal decrease in
RBC
Leukopoiesis
WBC production
Leukocytosis
Abnormal increase in
WBC
Leukopenia
Abnormal decrease
inWBC
Megakaryopoiesis
Megakaryocyte
production
Thrombopoiesis
Shedding of platelets
form megakaryocytes
Thrombogenesis
Generation of clot
Thrombocytosis
Increase in absolute
platelet count
Thrombocythemia
Increase in platelet
count in the
circulation
Thrombocytopenia
Decrease in platelets
Dyserythropoiesis
Abnormal RBC
production
Dysgranulopoiesis
Abnormal
granulocyte
production
Aplasia
Absent cell
production
Dysmyelopoiesis
Abnormal
development of
marrow cells
Panmyelosis
Abnormal increase in
all marrow cells
Pancytopenia
Decrease in all cell
types
Leukoerythroblastosis Increased WBC with
immature RBC
Thrombocytopathy
Condition
accompanied by poor
platelet function
Metaplasia
Change in the normal
cell production
process (production
outside the normal
location)

TERMINOLOGIES
Thrombosis

Disorder associated
with the presence of a
thrombus (clot)
Hemophilia
Attracted to or love of
blood
Idiopathic or immune Autoimmune disorder
thrombocytopenic
characterized by the
purpura
destruction of antibodycoated platelets by the
reticuloendothelial
system
Thrombotic
Decreased levels of
thrombocytopenic
platelets owing to
purpura
platelet consumption or
shortened lifespan

CONCEPTS OF NORMAL HEMOSTASIS

Normal Hemostatic Balance
o Old concept
- Hemostasis is the normal process by
which bleeding from injured vessel is
stopped through blood coagulation
o Advanced concept
- Hemostasis is a complex interaction
between blood vessels, platelets, and
biochemical reactants or coagulation factors
in the plasma
BALANCE OF HEMOSTASIS

COMPONENTS OF HEMOSTATIS
1. Extravascular components
- tissue surrounding blood vessels
- provides back pressure
Factors:
a. Type
b. Tone
c. Amount/Bulk
2. Vascular components
- vessels through which blood flows
o Arteries
o Veins
o Capillaries
Considerations:
a. Diameter of lumen
b. Integrity of endothelial lining
c. Thickness of muscular walls
3. Intravascular components
- platelets and many biochemicals
(procoagulant) in the plasma
- components are involved in either
coagulation or fibrinolysis

Hypocoagulation
o Abnormal bleeding
o Hemophilia
- lack of factor VIII
o Disseminated Intravascular Coagulation
(DIC)
- pre-consumption of platelets and
coagulation factors
- clot formation in different parts of the
body without a preceding injury
Hypercoagulation
o Thrombosis
- inappropriate formation of thrombi in the
vasculature which occlude normal blood
flow
o Thrombi
- clot
- consists: platelets, RBC, WBC, fibrin
*red- RBC trapped in white fibrin strands
*white- platelet plug with fibrin

o Deep venous thrombosis

- clots in deep areas of the limbs due to
injuries to the veins resulting in thrombosis
- complication: embolism

2. Platelet activation
- platelet plug formation
- platelet surface becomes available for
coagulation activities
- platelet-fibrin clot formation
a. Platelet deposition and adhesion
b. Platelet secretion
c. Platelet aggregation
3. Coagulation
a. Collagen exposure > intrinsic pathway
b. Tissue factor exposure > extrinsic
pathway
c. Common pathway > stable fibrin clot
4. Fibrinolysis
a. Tissue Plasminogen Activator (TPA)
release
b. Plasminogen
c. Plasmin- potent fibrinolytic agent
d. Clot dissolution as vessel heals
5. Tissue repair

HEMOSTATIC MECHANISM
PHASES OF HEMOSTASIS
a. Primary
- Involves the vascular and platelet
response to vessel injury
b. Secondary
- Includes the response of the coagulation
process to such injury
Result: stable fibrin-platelet plug
1. Vasoconstriction= nervous system response
+ vessel muscular response Factors:
a. Type of surrounding tissue
b. Depth of injury

ROLE OF BLOOD VESSELS

Intact Vessels
1. Capillary
- Smallest and most numerous blood
vessels in the body
- Lined with a single continuous
endothelial cell layer attached to a
supportive basement membrane
- Mediates metabolic and gas exchange
processes by diffusion through tight
junctions
*pericytes
- beneath the endothelium
- differentiate to endothelial
squamous cells
- back up cells

2. Arteries and Veins

Adaptive Measures of the Blood Vessels
- Able to constrict and dilate
- Can regulate blood flow rate and blood
1. Coagulation proteins are in the inactive
pressure
form
2. Endothelium is devoid of thrombogenic
Tunics:
factors
3. Brisk flow of blood removes activated
a. Tunica interna/intima
proteins
- direct contact with blood
4. 13-hydroxyoctadecadeionic acid (13- endothelium
HODE)
- collagen and elastic fibers
- Produced by endothelial cells
- Prevents platelet adhesion
b. Tunica media
- smooth muscle layer
Substances Released/Found on the Surface of Intact
- collagen
Endothelial Cells
- external elastic lamina with few
fibroblasts
c. Tunica externa/adventitia
- adventitial cells like fibroblasts
*lumen- space
*valve of veins- prevents backflow of blood
*smooth surface- maintains the liquid form
of blood

Artery

Vein

Damaged Vessels
1. Arterio-/Athero- sclerosis
- Crystallized cholesterol in blood vessels

3. Spider veins
- Veins are as thin as capillaries and dont
contain blood

2. Varicosity
- Damaged valves of veins
- The vein struggles to push the blood
upwards toward the heart
- Backflow of blood
- Overstretching of the walls of the veins
- Skin may bulge
- Irreversible

ROLE OF PLATELETS
*Qualitative and quantitative platelet abnormalities
can cause hypocoagulation or hypercoagulation
Roles
1. Adhesion to injured vessel
2. Aggregation at the injured site
3. Promotion of coagulation by their
phospholipid surface
4. Release of biochemicals important for
hemostasis from their alpha and dense
granules
5. Induction of clot retraction
COAGULATION
- Process whereby plasma coagulation
proteins, tissue factor, and calcium
interact on the cell surfaces to form a
fibrin clot at an injured site

Pathways

FIBRINOLYSIS
- System whereby the temporary fibrin
1. Extrinsic
clot is systematically and gradually
- Primary mechanism by which
dissolved as the vessel heals in order to
coagulation is initiated in vivo
restore normal blood flow
- Activated following vascular
- Damaged tissues release TPA which
endothelial cell injury
activates the inert and circulatory
- Evaluated by the prothrombin time test
precursor plasminogen to plasmin
*tenase complex: TF:VIIa + Ca++
*Plasmin
2. Intrinsic
- can degrade fibrin and factors I, V,
- Initiates the contact phase of
and VIII
coagulation and involves contact factors
(XIIa, XIa, IXa)
THE PLATELET STRUCTURE
- Evaluated by activated partial
thromboplastin time
Diameter: 1-4 um
++
*tenase complex: IXa + VIIIa + Ca +
Thickness: 0.5-1.0 um
phospholipids
MCV: 5-7fL
3. Common
Parts:
- Begins with the activation of Xa either
by the intrinsic or extrinsic pathway
*prothrombinase complex: Xa + Va + Ca++
+ phospholipids

*The Alternate Pathway

1. Plasma membrane (Hyalomere)

-7.5 nm thick
- trilaminar unit structure
a. glycocalyx (10-50nm)
-glycoproteins for platelet adhesion
(gpIb/IX x vWF) and aggregation (2
gpIIb/IIIa)
- surface for coagulation factors to
adhere
b. phospholipid constituents:
o phosphatidylserine (most common)
o phosphatidylcholine
o phosphatidylinositol
o phosphatidylethanolamine (new)
2. Submembrane area
- separates organelles in the inner matrix of
unaltered platelets (round) from the internal
side of the platelet cell wall
- contains organized system of filaments
(maintain length and diameter= platelets are
discoid)
*platelet activation- filaments protrude
making the platelet membrane follow the
filaments= alteration of platelet shape=
PSEUDOPOD FORMATION/VISCOUS
METAMORPHOSIS
3. Platelet Cytoskeleton/ Sol Gel Zone
- intraplatelet matrix
- matrix of platelet cytoplasm, microtubule
system, randomly arranged microfilaments=
supports the platelet's discoid shape
a. microfilaments contain fibers:
THROMBOSTHENIN- actin and
myosin
*exposure to aggregating
stimuli>reorganization of the peripheral rim
of microfilaments>tight central formation>
expulsion of megakaryocytic constituents:
-serotonin (vasoconstrictor) and platelet
-specific proteins (platelet factor III and IV)
b. microtubule system= extent of
contractile response of platelets to
stimulus
***Clot retraction: thrombosthenin, submembrane
area, cytoskeleton

4. Organelles
a. dense bodies
- 250-350 nm diameter
- 7 secretions
o ADP
- most important
- binds to specific receptors
(gpIIb/IIIa)> initiates platelet
aggregation
- promotes coagulation
*adenosine- inhibits platelet function
and coagulation by enhancing cyclic
AMP levels
o ATP- provides energy
o Calcium- divalent cation important
in the activation of membrane
phospholipases
o Magnesium
o Serotonin- vasoconstrictor
o GDP, GTP (guanosine)
b. alpha granules
- 300-500 nm
- 33 secretions
o platelet specific proteins:
-platelet factor 4 (PF4)
- beta-thromboglobulin family
(binds heparin)
- gpIIb/IIIa (receptor for fibrinogen
and vWF)
o multimerin- large molecular weight
protein
- same function as vWF
o adhesive glycoproteins:
-fibrinogen
-fribronectin
-vWF (storage: Weibel-Palade body)
-vitronectin
-thrombospondin
o coagulation factors:
- factor V
- factor XI
- protein S
o mitogenic factors- mitosis for repair
by proliferation of smooth muscle
cells (tunica media of blood vessels)
- platelet-derived growth factor
(PDGF)

- endothelial cell growth factor

~1/10 platelets = destroyed everyday > new
(ECGF): proliferation of endothelial platelets are added in the same proportion
cells
- transforming growth factor-B
Distribution: (freely interchangeable)
(TGBF): derives CFU-Baso from
2/3 platelets- circulation
CFU-Eo
1/3 platelets- spleen
- epidermal growth factor (EGF):
stimulate proliferation of other cells PLATELET FUNCTION AND PRIMARY
in the blood vessels
HEMOSTASIS
o fibrinolytic inhibitors
- alpha2-plasmin inhibitor
A. Adhesion
- plasminogen activator inhibitor 1
(PAI-1)
Factors:
o membrane-associated proteins
1. detached endothelial cells,
- P-selectin: together with integrin, it
subendothelium, media, adventitia
mediates the exit of neutrophils from
the blood vessels during chemotaxis
2. extent and depth of vessel wall injury
- GMP 33
*collagen, fibronectin, thrombospondin,
- 24-kD GTP binding protein
laminin, vitronectin= activated after injury
- gp IV (CD 36)
*endothelial cell desquamation
- Osteonectin: adhesive protein
*finger puncture: adhesion only
c. lysosomes
*atherosclerotic plaque- aggregation,
- destruction and degradation of
coagulation
substances ingested by platelets
*type of collagen exposed
- contains acid hydrolases:
1. Collagen types IV and V
o cathepsin
- endothelial cells
o collagenase: degrade collagen to
- immediately below
facilitate repair
endothelium
o elastase
- adhesion only
o enzymes for polysaccharides: for
2. Collagen types I and III
glycogen
- smooth muscle cells
o heparinase
- deeper (tunica media)
- adhesion, aggregation, release
THROMBOKINETICS
*vWF- plasma protein for platelet adhesion
Normal:
to collagen
rate of platelet release from megakaryocyte = rate
- link between gpIb/IX receptor
of platelet removal from circulation
complex and the subendothelial cell
connective tissue
Net turnover rate: 35 000+/-4 300 platelets/mL/day
3. age, hematocrit level, blood flow rate,
<50 000 platelet count= spontaneous bleeding
vessel size, shear rate
a. age: vessel wall elasticity
2 populations of platelets: (assessed by histogram)
b. shear rate- velocity of blood
1. young- hemostatically more effective
flow in relation to time
2. old- hemostatically less effective
greater diameter= low shear
- bigger; less glycoproteins
rate
narrow diameter= tension=
Life span: 7-10 days/ 9-11 days
high shear rate (high velocity,

delayed time)= stagnation of

blood flow= platelet
activation= vWF activation=
adhesion
4. various plasma proteins
Clinical Relevance:

proliferation and vessel wall hyperplasia

after platelet-vessel wall interaction
- permanent injury, no regeneration,
no/limited vasoconstriction
C. Aggregation
*Induced by:
Collagen
ADP
Thrombin
Epinephrine
thromboxane A2 (TxA2)

1. Bernard-Soulier Syndrome
- autosomal recessive
- gpIb absent
- gpIX sometimes absent
- homozygous state:
*Viscous Metamorphosis/Pseudopod Formation
o prolonged bleeding time
- precedes aggregation reaction
o thrombocytopenia (because of loss
- platelets change shape
of ATP)
- controlled by:
o giant platelets (lack of
o microtubule system direction
glycoproteins> swollen platelets)
o microfilament system
contraction
2. von Willebrand's disease
- mediated by:
- qualitative or quantitative vWF defects=
1. ADP
bleeding tendencies
- dense granules
- therapy: cryoprecipitate transfusion (factor
- stimulated by: collagen, epinephrine,
VIII concentrate)
TxA2
- receptor site= secondary irreversible
platelet aggregation
B. Release Reaction: Secretion
- recruit more platelets to participate in
weak stimulus= alpha granules
thrombotic response at the site of injury
strong stimulus= alpha and dense granules
- link platelet to platelet while waiting
*induced by:
for fibrin
collagen
2. Thrombin
arachidonic acid metabolites
- product of the common pathway
thrombin
- circulating procoagulant
epinephrine
- induce aggregation by:
thromboxane A2
a. stimulating ADP release
b. activating platelet membrane
Clinical Relevance:
phospholipases= initiate
formation of TxA2
Gray Platelet Syndrome
c. inducing platelet aggregation
- deficient alpha granules and their contents,
independent of the 2
normal dense bodies and lysosomes
mechanisms (without prior
- ghost like platelets
stimulation)
- pale platelets on PBS
- life-long bleeding tendency
3. Thromboxane A2 (TxA2)
*Platelet-Derived Growth Factor (PDGF)
a. directly promotes aggregation
Deficiency
b. together with ADP, it stimulates
- cationic protein from alpha granules
release reaction
- influences smooth muscle cell
c. vasoconstrictor

*ristocetin- mimic action of vWF in

vitro
4. Platelet-bound reaction: factors II, VII,
IX, X + activated platelet

*prostaglandins (PGI2)
- vasodilator
- aggregation inhibitor
*cyclooxygenase pathway
- inhibited by aspirin
- no TxA2= no aggregation
4. Arachidonic Acid

*lipooxygenase deficiency = primary

thrombocythemia= decreased adhesion;
normal aggregation
Clinical Relevance:
Glanzmann Thrombasthenia
- lack of platelet aggregation
PLATELET REGULATION OF
COAGULATION REACTIONS
- thrombin generation in plasma
1. Platelet factor 3 activity
tenase complex: IXa, VIIIa, X
prothrombinase complex: Xa, Va,
Ca++
assemble on the platelet surface
2. Prothrombin Activation
- thrombin conversion is 300 000
times faster on the platelet surface
than by factor Xa alone
3. Stimulated platelets are associated with
factors Va, VIII (VIII:vWF), XI, XII
*Va & VIIIa: Ca-dependent

5. Factor IXa + cofactor VIIIa activate

factor X= dependent on availability of
platelet phospholipids
6. Collagen + thrombin activate platelets=
appearance of phosphatidylserine on
platelet surface
7. Platelets release granular constituents
8. Platelet factor 4 activity
- thrombin generation
- target of heparin
OTHER BIOLOGIC FUNCTIONS OF
PLATELETS
1. Relation to Atherosclerosis
a. pathologic plug formation in small
arteries (ie. brachial artery)
-crystalized cholesterol bury
themselves in the vessel walls
-collagen IV and V are exposed
(superficial wound)= adhesion,
aggregation= plugs embolism
b. deposition of LDL (bad cholesterol) in
vessel walls
-macrophages ingest them> lipidfilled macrophages= deposition/
infiltration
-inflammation
-hemodynamic stress- high shear
rate
-proteins coat the area (fibrinogen,
albumin)= attract platelets= more
aggregation
2. Cancer Metastasis
-clot formation near the tumor=
fibrinolysis= collagenase and other
enzymes, lysosomes= kill cancer cells

- tumor cells produce imitations of platelet Cofactors:

Non-enzymatic Cofactors:
secretions> metastasis
V
I
VIII
Substrate protein fibrinogen
*platelet secretions:
TF
phospholipids
a. epidermal growth factors
HMWK
Ca++
b. endothelial cell growth factors
c. platelet-derived growth factors
COAGULATION AND THE KININ SYSTEM
3. Relation to Inflammation
- indicates repair (mitogens)
*platelets can ingest:
o Carbon
o Latex
o Collagen
o other lipids
INTRODUCTION TO COAGULATION
Coagulation
- involves a series of reactions that
involve coagulation factors as enzyme
precursors known as zymogens
- interaction of several plasma proteins

Kinin
- low molecular weight proteins
- involved in the intrinsic pathway
Functions:
1. act in pain sensation
2. involved in chemotaxis
3. mediate inflammatory responses
4. increase vascular permeability
5. cause vasodilation= hypotension
6. induce smooth muscle contraction
Groups:
1. prekallikrein
2. kallikrein
3. high molecular weight kininogens

Zymogen (inactive) >> serine protease (active)

*coagulation factors are normally present in plasma
Exceptions: Ca++, tissue factor (TF)
14 coagulation factors:
I-XIII (no VI)
Prekallikrein (PK)
High molecular weight kininogen (HMWK) COAGULATION FACTORS
Nomenclature of coagulation factors:
Factor __= zymogen
Factor __a= serine protease
Factor __f= fragmented

Grouped According to:

1. pathway
2. biologic similarities
3. similar properties

*Written in Roman numerals

Exceptions:
3 Basic Groups:
Factor III= tissue factor (TF)
Factor IV= Ca++
1. contact group: XII, XI, PK, HMWK
- activated upon contact with a negatively
Zymogens:
charged surface
II
XI
2. prothrombin group- II, VII, IX, X
VII
XII
3. fibrinogen group- I, V, VIII, XIII
IX
XIII
X
PK

INTRINSIC PATHWAY
- stimulus comes from inside the blood vessel

*XIIa- promoter of coagulation

*XIIf- inhibitor of coagulation

Collagen
- negatively charged surface which activates the
contact group

Hemostatic Role of XIIa and XIIf:

1. XIIa- initiator of the intrinsic pathway

*contact activation: collagen + XII + HMWK + PK

+ XI

XIIa
HMWK

Factor XII
- single chain polypeptide
- adsorbs itself to collagen to cause a
conformational change from being factor XII to
XIIa
Activation:

XI

XIa

XIIf- does not activate XI

Xia

2. XIIa and XIIf activate the extrinsic pathway

XIIa
[TF:VIIa]

HMWK, Kallikrein

1. XII

XIIa

XIIf

Activators (negatively charged surfaces):

Chemicals (ie. micronized silica, ellagic
acid, kaolin)
Platelets
Exposed collagen
2. XII

(in the absence of

Ca++)

alternate pathway of coagulation

Synergistic effect= faster clotting
Magnify the reaction= immediate fibrin production
3. XIIa and XIIf initiate fibrinolysis (clot lysis)
TPA= XIIa + Kallikrein

XIIa

Plasminogen

Plasmin

HMWK
XIIf

Plasminogen

autoactivation

4. XIIf initiates the kinin and the complement

systems for repair.

Kallikrein, Plasmin

3. XIIa

Plasmin

XIIf
XIIf

PK

Kallikrein
Loss of autoactivation function
Serine proteases involved:
HMWK
Kinin
HMWK- enhances the reaction of kallikrein
to factor XII
Kallikrein- converts XIIa to XIIa = XIIa, HMWK- if it is not converted, its constant
XIIf presence serves as a helper of kallikrein
XIIf

C1q

PK

Membrane Attack Complex

4. XIIa
XIIf
Kallikrein

HMWK

Kinin

Kallikrein
- from prekallikrein (PK)

3. activation by thrombin (+ feedback mechanism)

thrombin

Major Roles in Contact Activation:

1. perpetuate factor XII activation and its
own production
2. convert HMWK to other forms of kinin
(eg. bradykinin)
3. initiate fibrinolytic and complement
systems
Plasmin
Role in Contact Activation:
1. fibrinolytic agent
- gradual clot dissolution/fibrinolysis
forming Fibrin Degradation Products
(FDP)

XI

XIa

4. autoactivation
XI

XIa

Limitation of the 3rd and 4th Mechanisms of

Activation:
When there is enough fibrinogen
* or no factor XII= no manifestations
* or no factor XI= manifested by bleeding

2. inhibitor of coagulation

Factor IX

Excess plasmin bound by anti-plasmin

Activation:

XIIa

1. activation by factor XIa in the presence of Ca++

XIIf

XIa

3. activate kinin and complement system

Ca++

plasmin

XIIa

XIIf
PK

IX
kallikrein

HMWK

IXa

2. direct activation by kallikrein

kinin

Kallikrein

IX

Factor XI
Activation:
1. activation by factor XII and HMWK
XIIa

IXa

Factor VIII
- product of thrombin activation
- substrate of thrombin

HMWK

XI

XIa

Tenase Complex

2. direct contact activation by a negatively charged

IXa + VIIIa + Ca++ + phospholipids
surface

EXTRINSIC PATHWAY
- stimulus comes from outside the blood vessel
- more dominant pathway in vivo
Tissue Factor (TF)
- from the synthesis of all other cells of the body
except endothelial cells
- receptor protein for factor VII
- activates factor VII to VIIa in the presence of
Ca++
[TF:VIIa]Ca++ on endothelial cell
surfaces
Composition:
1. lipids- more important
- high affinity to factor VII
2. carbohydrate groups
*Prothrombin Time
Reagent= 1/3 of tissue factor containing
lipids only
Factor VII
- prothrombin group
- binds with TF in vivo
Activation:
1. tissue factor + calcium
2. kallikrein
3. thrombin
4. XIIa
5. XIIf
6. IXa: alternate pathway
7. Xa: - feedback mechanism
a. activation of [TF:VIIa]
b. inhibition of [TF:VIIa]

COMMON PATHWAY
Tenase Complex:
IX + VIIIa + Ca++ + PL
[TF:VIIa] Ca++

Platelet Factor 3
activity

Factor X
Activation:
X

Xa
+ Va
+ Ca++
+ PL

= Prothrombinase
complex

Factor II
Activation:
prothrombinase complex

II

IIa

IIa has a (+) feedback mechanism on factors: V

VII
VIII
XI
IIa in excess has a (-) feedback mechanism on the
activity of factors: V
VIII
prothrombinase complex

II

prothrombin 2
Hydrolysis of disulfide
bonds by the prothrombinase
complex

Tenase Complex
[TF:VIIa] Ca++

thrombin fragment 1.2

thrombin fragment 1.2.3

fully functional
IIa

Thrombin (IIa)
Roles:
1. factor I activation
IIa

Ia

2. factor XI activation

Factor XIII

IIa

XI

XIa

Activation:
IIa, Ca++

3. factor VIII activation

IIa

VIII

VIIIa

4. factor V activation
IIa

Va

5. factor XIII activation

XIII

XIIIa

XIIIa- transaminase which joins covalent bonds of

fibrin polymers
Fibrin
Monomer
Solubility
Soluble
Composition Fibrinogen
without
fibrinopeptides

IIa

XIII

XIIIa

Factor I
- glycoprotein circulating in plasma
Composition:
1. 2 A chains
2. 2 B chains
3. 2 chains- unreacted molecules
4. 2 fibrinopeptide A- 16 amino acids
5. 2 fibrinopeptide B- 14 amino acids

Fibrin Thread/Clot
Insoluble
Fibrin monomers
joined together to
form polymers
stabilized by
factors XIIIa, IIa,
and Ca++

*Duckerts Test- solubility test for factor XIII

activity
reagents: 5M urea
1% monochloroacetic acid
ALTERNATE/CROSS-OVER PATHWAYS
1. XIIa

[TF:VIIa] Ca++
Steps in Fibrin Thread Formation:
XIIf
1. Enzymatic step
- thrombin ats on fibrinogen
2.
[TF:VIIa] Ca++
molecule to remove the
fibrinopeptides and replaces it with
IX
IXa
the fibrin monomer which is soluble
3. autocatalytic pathway
2. Polymerization step
- several fibrin monomers = fibrin
IIa
polymer
XI
XIa
a. release of fibrinopeptide A
- side-to-side bonding
IIa
b. release of fibrinopeptide B
- end-to-end bonding
VIII
VIIIa
3. Stabilization step
- cross linkage of adjoining
polymers

IIa
V

Va

4. negative feedback of Xa
Xa

Activation:

[TF:VIIa] Ca++

1. intrinsic (in vivo)

XIIa + kallikrein
XIIf
HMWK
XIa

THROMBIN BIPOLARITY

plasma plasmin
proactivators

1. promotes coagulation
a.
Fibrinogen group

2. extrinsic (in vivo)

- from protease-secreting tissue organs
eg. myocardium, prostate, uterus

IIa
active forms

b. self-perpetuating (autocatalytic
pathways)
c. enhances platelet aggregation
2. inhibits coagulation

3. exogenous (in vitro)

Urokinase
Streptokinase
Other lysosomal enzymes (tears, semen,
saliva, breast milk)
Plasmin
- active form of plasminogen

a. destroys factor V and VIII activities

b. activates protein C which is a fibrinolytic Roles:
agent bound to thrombomodulin on the
endothelial surface
1. physiologic: clot dissolution
Fibrin Degradation Product (FDP)
FIBRINOLYSIS
- byproduct of solid fibrin clot
- gradual dissolution of the clot
- last mechanism activated during injury
2. pathologic: destruction of the fibrinogen group
- prevents vessel occlusion and to restore blood
Fibrinogen Split Product (FSP)
flow
- byproducts of the action of plasmin on
the fibrinogen group
TPA
*anti-plasmin: 2- anti-plasmin
prevents FSP
Plasminogen
Plasmin (proteolytic
2- macroglobulin formation
enzyme)
Clot (platelets+fibrin)
Plasminogen
- glycoprotein synthesized by the liver
- molecular weight: 90 000 kD
- stored and transported by eosinophils
- structurally embedded in eosinophils
- adsorbed by fibrin

FDP and FSP Formation:

Substrates: Fibrin (clot)
Individual factors of the fibrinogen
group

*Protamine Sulfate Assay- test for paracoagulation

- sometimes uses ethanol
- (+) result shows
precipitation
INHIBITORS OF COAGULATION

plasmin

1. anti-thrombin III (AT-III)/ heparin cofactor I

- inhibits thrombin and the contact group
early
- neutralizes thrombin action
degradation
- enhanced by:
plasmin
products
o heparin
- attaches to AT-III making a big
Y-fragment: YY, DXD
molecule that easily binds with
thrombin
plasmin
- accelerates neutralization rate
*heparin therapy for patients
DED, DY/YD
with myocardial infarction and
hypertension maintains blood in
plasmin
the liquid form
D and E fragments
o heparan sulfate
- late degradation products which
- heparin-like activity on cell
are cleared by the
surfaces
reticuloendothelial system (liver,
- found in vascular endothelial
spleen, kidneys)
cells
- if it is not cleared, it has
- protects the uninjured blood
pathologic effects
vessel by rejecting thrombin
immediately
*D-dimer Test- indication of in vivo fibrinolysis
- acquired deficiency: DIC
= no anti-plasmin
Thromboembolic
= bleeding/thrombosis
diseases
shock
Pathologic Effects of FDP:
Impairs hemostatic processes by damaging
2. heparin cofactor II
intravascular coagulation and fibrinolysis
- primary inhibitor of thrombin
- activated by heparin and other
1. demonstrate anti-thrombin activity
mucopolysaccharides like heparan sulfate
2. form incoagulable or slowly coagulable
and dermatan sulfate
complexes with fibrin monomers or
- doesnt inhibit plasmin
fibrinogen
3. generally inhibit coagulation
3. 2- macroglobulin & anti-plasmin
a. Y fragment- most potent inhibitor
- large structure
of coagulation
- entraps coagulation enzymes and thrombin
b. Y & D- inhibit fibrin
- inhibits kallikrein and plasmin
polymerization
c. E- direct inhibitor of thrombin
4. 1- antitrypsin/1-antiprotease
4. lead to pathologic fibrinolytic states
*trypsin- one of the activators of factor XII
Fibrin monomer + FDP = gel
- potent inhibitor of factor XIa and
paracoagulation/false coagulation
fibrinolysis which is produced by the liver
X-fragment- 1st and largest fragment
- MW: 250 000 kD

- it protects the liver against clot formation

- can inactivate thrombin at a very slow rate
- requires normal pulmonary function
- deficiency caused by liver cirrhosis causes
pulmonary diseases like emphysema and
other thromboembolic disorders

- preserves the clot

- inhibits TPA
- deficiency: DIC (increased
fibrinolysis) manifested by severe
bleeding tendencies
3. 2- macroglobulin
- inhibits plasmin

5. C1 inactivator/C1 esterase inhibitor

- inactivates C1 of the complement system
- inhibits coagulation, fibrinolysis,
4. antithrombin III
complement, and kinin systems
- inhibits plasmin and kallikrein
6. protein C & protein S
- inhibit coagulation when activated
- enhance fibrinolysis by inhibiting PAI
- inhibit factors V and VIII
- deficiency: clotting tendencies
Activation:
Protein C + thrombomodulin + Ca++ +
thrombin + Protein S = activated protein C

5. C1 inhibitor
- inhibits plasmin
Sequence of Consumption of Inhibitors:
2-antiplasmin> 2-macroglobulin> 1-antitrypsin
NATURAL INHIBITORS OF COAGULATION

7. protein C inhibitor
1. heparin/antithrombin
- heparin-activated serine protease
- inhibits: Factor X activation to Xa
- inhibits protein C, factor Xa and IIa
Thrombin
- deficiency: factors V and VIII deficiencies
Factor XI activation to XIa
Factors V and VIII activities
8. tissue factor pathway inhibitor (TFPI)
- binding of Xa to [TF:VIIa] Ca++ to stop the 2. protein C pathway
extrinsic and common pathway, hence
- involves: thrombomodulin
stopping fibrin formation
Protein C
- aided by heparin
Protein S
INHIBITORS OF FIBRINOLYSIS

3. TFPI
- inhibits factor Xa and [TF:VIIa] Ca++
binding

1. plasminogen activator inhibitor I (PAI-I)

- inhibitor of TPA and urokinase preventing
the production of plasmin
CONTROL MECHANISMS OF
- from the granules of aggregated platelets PHYSIOLOGIC COAGULATION
- response to the action of thrombin
- inhibitor of protein C and thrombin
1. vascular endothelium
- can be destroyed by factor XIa
- devoid of thrombogenic substances
- deficiency: excessive fibrinolysis
- coagulation proteins are in the inactive
form
2. 2- antiplasmin
- brisk flow of blood removes activated
- principal inhibitor of fibrinolysis
proteins
- binds and neutralizes plasmin
- 13-hydroxyoctadecadeionic acid (13- incorporated by the covalent bond during
HODE) prevents platelet adhesion
the stablilization step of fibrin thread
formation
2. inhibiting processes at the site of clot formation

*clot formation is a self-limiting process

3. clearance mechanisms for coagulation
components
a. hepatic clearance
- FDP and FSP, which are remnants
of coagulation and fibrinolysis, are
cleared by the liver
b. pulmonary vascular bed
- clears soluble components like
factors IXa and VIIa by the
mechanism of sneezing
c. WBCs and macrophages
- clear larger debris

DISORDERS OF PRIMARY HEMOSTASIS

- manifestations:
a. fragile capillaries (positive tourniquet
- involves interaction of platelets and blood vessels
test)
- affect tests for bleeding time and platelet count
b. serious bleeding (gum bleeding in adults)
c. coiled hair
Bleeding Disorders Due to Vascular Defects
d. frog leg position in children
- normal vitamin C intake: 500 mg
primary sign of bleeding: petechiae
2. Senile Purpura
A. Hereditary Connective Tissue Disorders
- affects the elderly
- bleeding due to the degeneration of collagen
Connective tissues
- manifestations:
- provide back pressure for the collapsing blood
a. ecchymotic spots
vessel
- decrease in albumin
- comprise majority of the blood vessel
- hemoglobin is not transported
- deposition of macrophages
1. Ehlers-Danlos Syndrome
b. easy bruisability
- affects: connective tissues, blood vessels, bones
- lack of structural tissue support
C. Hereditary Alterations of the Blood Vessel Wall
- 3 mechanisms:
a. deficiency of peptidase enzyme which
1. Hereditary Hemorrhagic Telangiectasia
converts procollagen to collagen
- small blood vessels are dilated
b. abnormality in the procollagen molecule - poor wall support
c. abnormality in the cross-linking of
- diminished contraction of the blood vessel
mature collagen
- manifestations:
- manifestations:
a. prolonged bleeding
a. hypermobile joints
b. spider veins
b. hyperextensible skin
- no ecchymosis and purpura
c. large ecchymoses and hematomas
- treatment: iron supplement
d. bleeding (gums, post-partum, GIT)
- treatment: none
2. Cavernous Hemangioma/Kasabach Merritt
Syndrome
2. Pseudoxanthoma Elasticum/Lax Skin
- tumor within the blood vessel
- abnormality in the elastic fibers
- cavernous = strawberry (red/pink)
- manifestations:
- tumor characteristics:
a. easy bruisability
a. filled with blood
b. hemorrhagic spots
b. fibrin clots formation within the tumor
c. subarachnoid and GIT bleeding- cause of
c. platelet consumption
majority of deaths
d. RBC destruction
- similar manifestations with DIC
B. Acquired Connective Tissue Defects
D. Acquired Alterations of the Blood Vessel Wall
1. Scurvy
- vitamin C deficiency
1. Diabetes Mellitus
- purpose of vitamin C:
- atherosclerotic blood vessel
a. collagen synthesis
- thickened capillaries that block blood flow
b. binds endothelial cells together
- slow healing or no healing of blood vessels
- malformation of collagen
- necrosis

2. Amyloidosis
- deposition of fibrillary proteins

Platelet Disorders
Quantitative

E. Other Causes of Vascular Damage

1. Autoimmune Vascular Purpura
a. Drug-induced Purpura
- aspirin (destroys cyclooxygenase
pathway)
- quinine
- procaine
- anti-malarial drugs
- sulfonamides
- strong antibiotics
- sedatives
- Coumadin
b. Allergic Purpura
- perfusion of blood from vessels
c. Henoch-Schonlein Purpura
- GIT bleeding/abdominal bleeding with the
involvement of joint pain (wrists, ankles,
knees)
- deposition of IgG, IgA, C3 mostly in the
kidneys
- cutaneous manifestations
2. Infectious Purpura
a. Bacterial
- tuberculosis
- scarlet fever
- typhoid fever (rashes on the abdominal
area)
- diphtheria
- endocarditis
b. Viral
- smallpox
- influenza
- measles
c. Rickettsial
- rocky mountain spotted fever
d. Protozoal
- malaria

A. Thrombocytopenia (<140 000 platelets/mm3)

- 3 mechanisms:
rate of platelet production is insufficient to
meet the need
rate of platelet production is decreased
rate of platelet loss is increased
- dengue fever, parvovirus B19 infection
- classifications:
1. Decreased Production
a. Megakaryocytic hypoproliferation/
hypoplasia
Inherited
o Fanconi anemia
- hereditary non-production of all
types of cells
- affects the hematopoietic stem
cells
- autosomal recessive disorder
common among Jews
- manifestations:
short stature
strabismus
low set ears
frequent infections
chances of deafness
hypoplastic thumb
(abnormal or absent)
hypopigmentation
aplastic anemia
thrombocytopenia at 18
months to 10 years
- treatment: bone marrow
transfusion
o Thrombocytopenia with absent
radius (TAR)
- no radius (forearm)
- in adults, hematopoiesis occurs in
the proximal spaces of the long
bones
- 90% of neonates with this
condition die during the first year of

life
- the remaining 10% survive but
become mentally retarded due to
plasma deposition and precipitations
in the brain
o Amegakaryocytic thrombocytopenia
- low levels of platelets due to
absence of mature megakaryocytes
in the bone marrow
- normal delivery, immediate death
due to bleeding
Acquired
o Aplastic anemia
- acquired non-production of all cell
types
- generalized bone marrow
suppression affecting all cell lines
- causes:
Toxic chemical agents
Physical agents
Radiation
Viral infections
Drugs
- chloramphenicol (strong
antibiotic)
- chlorothiazide (diuretic for
hypertensive patients)
- cisplatin and carboplatin
(anti-cancer)
- anagrelide (anti-platelet)
o Myelophthisic thrombocytopenia
- crowding out mechanism
- disorders involved:
Myelofibrosis
- abnormal deposition of
fibrous connective tissues in
the bone marrow
Metastatic cancer
- only tumor cells
Leukemia
- abnormal proliferation of
WBC precursors
Hodgkins and nonHodgkins lymphoma
Microangiopathic hemolytic
anemia
- schistocytes

o
o
o
o

Osteopetrosis
- no bone marrow cavity
- lifespan: up to 2 weeks
postpartum
Prolonged hypoxia
- lack of oxygen supply
- increased RBC production,
decreased platelet production
- detected by peritubular capillaries
in the kidneys which trigger
erythropoietin production
stimulating bone marrow action to
proliferate CFU-E for RBC
production
May Hegglin Anomaly
- Dohle/Amato bodies in WBCs
- thrombocytopenia (20 000120 000/mm3)
- giant platelets (MPV: 15-20um)
- production of platelet-associated
IgG
Bernard Soulier Syndrome
- gp Ib/IX is absent or deficient
- attachment to the endothelium is
not possible
- platelets try to adhere to the
endothelium and consume ATP
- ATP depletion, decreased platelet
count
Wiskott Aldrich Syndrome (WAS)
- excessively small platelets
- severe thrombocytopenia because
more platelets are required even for
small injuries
Paris-Trousseau Syndrome
- increased micromegakaryocyte
which are mature megakaryocytes
which are as small as small
lymphocytes
- 15% of platelets show giant alpha
granules because of fusion of
granules in the small cytoplasm of
the megakaryocyte
Drug toxicity
Alcohol toxicity
Viral infection
Congenital states

b. Ineffective thrombopoiesis

deposit in some parts of the body

Inherited
2. Increased Loss or Destruction
o normal or increased megakaryocytes
with normal lifespan
a. non-immunologic
- 90% of platelets die before
o loss
reaching circulation because of lack
severe hemorrhage
of ATP
extensive transfusion
o consumption
Acquired
disseminated intravascular
o megaloblastic anemia
coagulation (DIC)
- lack of vitamin B12 and folate
thrombotic thrombocytopenic
which are important for mitosis
purpura (TTP)
- impaired DNA synthesis
- constant platelet activation
o paroxysmal nocturnal
- diffuse thrombus formation
hemoglobinuria (PNH)
- increased levels of very large
- increased susceptibility to the lytic
multimers of vWF which are
activity of the complement
bound by platelets to form clots
- RBC destruction
hemolytic uremic syndrome
o thrombopoietin deficiency
(HUS)/uremia
- thrombopoietin stimulates the
- damages the kidney
release of platelets
- intraglomerular thrombi
o ethanol abuse without malnutrition
formation with renal
(alcoholism)
dysfunction, proteinuria and
- ethanol suppresses thrombopoiesis
hematuria
- reduction in platelet lifespan
- markers (thrombomodulin) are
o severe iron-deficiency anemia
exposed giving false signals of
- needed by megakaryocytes to
an injury
mature
thermal injury
- abnormal platelet release
sepsis without DIC
o viral infections
o miscellaneous
- dengue, chikungunya
dilutional loss
- extensive transfusion:
c. Marrow replacement
>acute blood loss
- crowding out mechanism
>platelet consumption
o leukemia
>dilution of platelet pool
- abnormal WBC precursors
artificial surfaces
o plasma cell dyscrasia
- proteins attach to foreign
o metastatic carcinoma
substances attracting platelets
o myelofibrosis
>cardiovascular prosthetic
- abnormal deposition of fibrous
valve
connective tissue
>artificial organs
o lymphoma
>prosthetic vascular grafts
- abnormal WBC proliferation
>dialysis membrane
o granulomatous infection
drugs
- granulocytes ingest
- cause platelet clumping
microorganisms but are not able to
>ristocetin
kill them
>heparin
- granulocytes increase in size and

infections
- sepsis-induced
thrombocytopenia
>direct interaction of
bacterial toxins with platelets

b. immunologic
-HPA-1a (Human Platelet Antigen)
>most antigenic platelet antigen
>IgM & IgA: liver
>IgG: spleen
>causes platelet injury
> absent in 3% of Caucasians
> present in 100% Asians
o isoimmune
- alloantigens (HPA-1a)
neonatal autoimmune
thrombocytopenic purpura
(NATP)
post-transfusion purpura (PTP)
refractory to platelet transfusion
- multiple transfusion
- antibody production
- involves: aplastic anemia and
acute leukemia
o autoimmune
- autoantibodies against the platelet
glycoproteins
- phagocytosis by the Fc receptor
mechanism
- complement activation
- autoantibodies that bind
megakaryocytes in the bone marrow
primary
idiopathic thrombocytopenic
purpura (ITP)
- management & treatment:
Avoid aspirin
corticosteroids
interferon
IV anti-D
cyclosporine
splenectomy
>acute ITP
- 2-6 years old
- <30 000/mm3 in
which 90% patients
have bleeding

episodes
- <10 000/mm3
spontaneous bleeding
- <1% cases:
intracranial bleeding
>chronic ITP
- 20-40 years old
- hypermenorrhagia
- easy bruising
- petechiae
- purpura
- prolonged bleeding
and abnormal clot
retraction time
disease associated
secondary
lymphoproliferative
disorders
- chronic lymphocytic
leukemia
- hodgkins disease
miscellaneous conditions
- rheumatoid arthritis
- SLE
- Crohns disease
infectious diseases
- bacterial
- HIV

o drug-induced immune
thrombocytopenia
- mechanisms:
formation of an antibody
against a drug-platelet
complex
drug-plasma protein complex
that binds to the platelet
drug-induced synthesis of
platelet autoantibody
- drugs:
quinidine
quinine
gold salt
sulfonamide
chloroquine
rifampicin
o virally-induced
- dengue

3. Splenic Sequestration
- 1/3 of the platelet population is found in the
spleen
- in case of splenomegaly, the spleen can
accommodate more platelets causing a decrease in
circulating platelets
- increased phagocytosis and destruction of
damaged platelets
a. Gouchers disease
b. sarcoidosis
c. Feltys syndrome
**Significant Values**
- the degree of thrombocytopenia is directly
proportional to the severity of bleeding
100 000/mm3: normal bleeding time (no aspirin
intake)
<100 000/mm3
>50 000/mm3 with normal platelet function:
monitor every 24 hours if there is no familial
history of bleeding
<60 000/mm3: abnormal clot retraction time
<50 000/mm3: severe thrombocytopenia; hydrate
the patient
<20 000/mm3: spontaneous bleeding

d. post-operative
e. infections and inflammatory diseases
o acute
o chronic
- tuberculosis
- ulcerative colitis
- sprue
- rheumatoid arthritis
- osteomyelitis
f. neoplasms
o carcinoma
o Hodgkins disease
C. Thrombocythemia (>450 000 platelets/mm3)
- increased platelet counts associated with chronic
myeloproliferative disorders
- association of megakaryocyte volume and
leukocyte count
<1 000 000 platelets/mm3
- Reactive thrombocytosis
- Transient
>1 000 000 platelets/mm3
- essential thrombocytosis
- persistent
- treatments: busulfan, hydroxyurea, recombinant
interferon-, anagrelide

B. Thrombocytosis (>450 000 platelets/mm3)

-classifications:
Qualitative
1. Primary Chronic Myeloproliferative Disorders
(CMPD)
a. Essential thrombocytopenia
b. Polycythemia vera
c. Chronic granulomatous leukemia
d. Myelofibrosis with myeloid metaplasia

Thrombocytopathy
- abnormal platelet functions
A. Inherited
1. Adhesion Defects

2. Reactive
a. physiologic
b. iron-deficiency anemia
- decreased RBC
- many platelets
c. rapid blood regeneration
o acute blood loss
o hemolytic anemia
o rebound

a. Bernard-Soulier Syndrome
- point mutation in the codon 129 of the
gpIb a gene
- lack of glycoprotein Ib/IX
- laboratory findings:
o bleeding time: 20 minutes
o CRT and PF3: normal
o aggregation tests with

ristocetin: abnormal
ADP, epinephrine,
arachidonic acid: normal
collagen, thrombin: variable
o giant platelets
b. Platelet type (pseudo) von Willebrands
Disease
- single point mutation resulting in a single
amino acid substitution at residue 233 or
239 of gp Ib/IX
- abnormally enhanced binding of platelets
to vWF
- laboratory findings:
o bleeding time: prolonged
o ristocetin platelet aggregation:
hypersensitive
2. Aggregation Defect
- deficient gp IIb/IIIa
- platelets cant undergo viscous metamorphosis

o Wiskott-Aldrich Syndrome
- triad: thrombocytopenia, recurrent
infections, eczema
- small platelets
o Hermansky-Pudlak Syndrome
- no dense granules
o Chediak-Higashi Anomaly
- affects all cells containing
lysosomes
- giant lysosomes
- prolonged bleeding
b. granule release defect
o Prostaglandin deficiency
- thromboxane A2 deficiency
o Cyclooxygenase deficiency
- 12-HETE deficiency
B. Acquired

1. drugs
a. Aspirin: destroy cyclooxygenase pathway
Glanzmann Thrombasthenia
b. Carbenicillin: interact with glycoproteins
a. Type 1
c. Alcohol: impair PF3 activity, inhibit
- no clot formation
thromboxane A2 release, impair
- absent gp IIb/IIIa
prostaglandin synthesis
b. Type 2
d. Dextran and related plasma expanders:
- at least 15% of gp IIb/IIIa is
dilutional effect
Present
e. Dipyridamole: increase conversion of
- laboratory findings:
ADP to adenosine (cAMP activity)
o platelet factor 3: deficient
*ADP- aggregating agent
o bleeding time: markedly prolonged
*adenosine- anticoagulant
o no aggregation with ADP,
2. diet
epinephrine, collagen, thrombin
a. High amounts of fish
o agglutination with ristocetin
b. Herbs (szechwan)
o normal platelet lifespan, count and
c. Onions
morphology
d. Garlic
e. B12 and folate deficiency
3. Release Defects
f. Increased vitamin E (normal 400IU)
- abnormal ATP release secondary to lack of alpha
- destroys prostaglandin synthesis
and dense granules
3. diseases
a. storage pool disease
o Gray Platelet Syndrome
- lack of alpha granules
- large platelets that stain gray or
blue gray

C. Myeloproliferative Disorders
1. uremia/ hemolytic uremic syndrome
- production of urea metabolites (guanidosuccinic
acid and phenolic acid) that inhibit platelet
aggregation

- large hypogranular platelets

2. disseminated/diffuse intravascular coagulation
(DIC)
- consistent clot formation
- increased FDP formation in plasma which bind
with platelet glycoproteins
- acquired storage pool disorders
- platelets cant release contents of alpha and dense
granules because they are not activated due to
premature binding by FDP products
3. immunoglobulin production
- antibodies bind with platelets
- platelets become non-functional
- decreased platelet lifespan
- splenic sequestration
DISORDERS OF SECONDARY HEMOSTASIS
Coagulation Disorders
Inherited

c. HMWK Deficiency
- autosomal recessive disorder
- poor contact phase reactions
- deficiency of kinin formation
- defective fibrinolysis reactions
- laboratory findings:
o Mildly prolonged PTT
d. Factor XI Deficiency/Hemophilia
C/Rosenthal Syndrome
- autosomal dominant
- common among the Jews
- mild bleeding
- symptomatically silent until stressed by
trauma or surgery
- clinical manifestations:
o Episodes of expistaxis
o Hematuria
o Menorrhagia
- laboratory findings:
o Prolonged PTT
- mixing studies:
o Corrected by adsorbed plasma
and aged serum

1. Intrinsic Pathway Defects

a. Factor XII/Hageman Factor Deficiency
- autosomal recessive disorder
- no bleeding
- more vulnerable to thrombosis (no direct
activation of plasminogen to initiate
fibrinolysis)
- laboratory findings:
o All tests normal except PTT
- mixing studies:
o Corrected by adsorbed plasma
and aged serum
b. PK/Fletcher Factor Deficiency
- autosomal recessive disorder
- no bleeding
- more vulnerable to thrombosis (no
kallikrein)
- laboratory findings:
o Shortened PTT when plasma is
incubated with surface activators
like kaolin

e. Factor X Activation Phase Disorder

- serious bleeding disorder
- disorders of the tenase complex
- defective factor VIII:C and IXa
f. Factor VIII:C Deficiency/Hemophilia A/
Classic Hemophilia
- sex-linked recessive disorder
- transmitted by carrier women to their sons
- clinical manifestations:
o Bleeding diathesis
o Hematoma
o Hemarthrosis
o Epistaxis
o Hematuria
o GIT or intracranial hemorrhages
o Post-operative bleeding
o Crippling of joints (blood
deposition in joints which
eventually crystallizes)
- laboratory findings:
o Prolong PTT
- mixing studies:
o Corrected by adsorbed plasma

g. Factor IX Deficiency/Hemophilia B/
Christmas Disease
- sex-linked recessive disorder
- milder form of hemophilia
- dysfunctional factor IX molecule or
decreased concentration of the molecule
- laboratory findings:
o Prolonged PTT
- mixing studies:
o Corrected by aged serum
h. von Willebrands Disease
- vascular fragility
- clinical manifestations:
o Vulnerability to bruising
o Epistaxis
o Menorrhagia
o Hemorrhage
- laboratory findings:
o Prolonged BT
o Prolonged PTT
o Decreased factor VIII:C
o Abnormal ristocetin-induced
platelet agglutination or
aggregation (vWF:RCoF)
NOMENCLATURE OF FACTOR VIII AND
vWF
1. VIII/vWF
- entire molecule as it circulates in plasma
- composed of VIII:C and vWF protein portions
2. vWF
- glycoprotein for binding to endothelium
- supports normal platelet adhesion and function
- carrier protein of VIII:C
3. vWF:Ag
- measured by immunoassay
4. VIII:C
- intrinsic system cofactor to IXa in the conversion
of X to Xa
5. vWF:RCoF
- ristocetin cofactor activity
- induces binding of vWF to platelet
- reaction is measured by aggregometry
6. vWF:Co
- Botrocen (snake venom) cofactor activity
- detects vWF by inducting binding of vWF to
platelets

7. vW AgII
- released by platelets and endothelial cells along
with vWF
- not detected by immunoassays
2. Extrinsic and Common Pathway Defects
a. Factor VII Deficiency
- clinical manifestations:
o Hemorrhage of mucus
membranes and into soft tissues
- laboratory findings:
o Prolonged PT
o Normal PTT
o Normal thrombin clotting time
b. Factor X/Stuart-Prower Factor
Deficiency
- clinical manifestations (life-long):
o Bruising
o Hematoma
o Post-surgical or post-trauma
hemorrhage
- laboratory findings:
o Prolonged PT
o Prolonged PTT
o Abnormal prothrombin
utilization
- mixing studies:
o Corrected by aged serum
- treatment:
o Konye80
- frozen plasma component or
prothrombin complex therapy
c. Factor V/Labile Factor Deficiency/Owren
Disease
- mild to moderate hemophilia
- laboratory findings:
o Prolonged PT
o Prolonged PTT
- mixing studies:
o Adsorbed normal plasma
- treatment:
o FFP infusion

d. Factor II Deficiency
- mild bleeding tendencies
- laboratory findings:
o Prolonged PT
o Prolonged PTT
- treatments:
o Konye80
o FFP
e. Factor I Deficiency
- varying hemorrhages
- laboratory findings:
o prolonged thrombin time
o prolonged reptilase clotting time
Afibrinogenemia
- inherited lack of fibrinogen
- clinical manifestations:
o Spontaneous bleeding
o Poor wound healing
- laboratory findings:
o All tests prolonged
Hypofibrinogenemia
- inherited deficiency of fibrinogen
Dysfibrinogenemia
- inherited production of
dysfunctional fibrinogen molecule
f. Factor XIII Deficiency
- clinical manifestations:
o Poor wound healing
o Unusual scar formation
- laboratory findings:
o Duckerts test: soluble
Acquired
1. Hepatic Disease
- laboratory findings:
o Prolonged PT
o Prolonged PTT
o Prolonged TCT
o Prolonged BT
o Increased platelet count
o Increased fibrinogen level
o Increased FSPs
- therapy:
o Fresh plasma infusion

2. Vitamin K Deficiency
- no prothrombin group (II, VII, IX, X)
3. Therapeutic Coagulation
a. heparin
- monitored by APTT
b. coumarin drugs
- oral anticoagulant
- monitored by PT
4. Circulating Anticoagulants/Inhibitory Substances
- Lupus anticoagulant in SLE (antiphospholipid
antibody)
- laboratory findings:
o Prolonged PTT
o Increased FDPs and FSPs
5. Massive Transfusion Effects
- dilutional effect
6. Artificial Surface Effects
- formation of thrombi and emboli
- consumption of procoagulant proteins and
platelets
- alteration of the function of these proteins
- incitement of systemic syndromes
7. DIC
- hypocoagulation
- laboratory findings:
o Prolonged TDT
o Prolonged PT
o Prolonged PTT
o Decreased platelets
o Decreased fibrinogen
o Decreased AT-III
o Increased FSPs
o D-Dimer (+): physiologic fibrinolysis
- treatment:
o Heparin (conditions)
- thrombosis damages the organ function
- no contraindications
- reversal of damage is possible
8. Primary Fibrinogenolysis (PF)
- excessive plasmin activity without fibrin clot
formation
- excessive FSPs

- difference between DIC and PF

PF
Euglobulin
Shortened
clot lysis
time
Platelet count
>100 000/
mm3
AT-III level
Normal
D-dimer test
(-)

formalin, brilliant crystal

blue
- sample: EDTA blood
- deep blue to purple circular
refractile platelets
o Unopette Method
- anticoagulant: potassium
oxalate
- prone to contamination

DIC
Normal or
slightly
shortened
Low
Decreased
(+)

- treatment:
o Natural antiplasmins
- bovine parotid extract (aprotinin)
o Synthetic lysine analogs
- epsilon aminocaproic acid (EACA)
- tranexamic acid

ii.

Indirect
o Fonios Method
- a hypotonic solution (14%
MgSO4) makes the platelets
swell for better visibility
- pink to purple large
granular platelets with
projections
- platelet count x RBC count

iii.

Platelet Estimation
- PBS
- count in 10 fields
- platelet count x 15 (PEF)
10 fields
- PEF = platelet estimation factor
- 8-20/OIO = adequate
- <6/OIO = low
- >25/OIO = high

TEST DETERMINATIONS FOR

COAGULATION
1. Primary Hemostasis
- tests for blood vessel integrity and
quantitative properties of platelets
a. Capillary fragility test/ tourniquet test
- tests the ability of capillary endothelial
cells to stay intact upon applying
100mmHg pressure for 5 minutes
- non-specific
- (+) result: petechiae
>5 for males
>10 for females
- presumptive for dengue
b. Bleeding time
- tests the time it takes a standard wound
to stop bleeding
- universal test for the evaluation of
hemostasis
- standard method: Simplate method
- children: Dukes method

2. Secondary Hemostasis
a. Intrinsic Pathway
i.

Lee & White Whole Blood

Clotting Time
o Principle: All coagulation
factors are present in whole
blood. If whole blood comes
in contact with a negatively
charged surface, clotting
happens
o Linearity: 1 minute
o Normal Value: 5-15 minutes

ii.

Activated Clotting Time

- point of care testing
o Principle: Same with
LWWBCT. Uses 12mg of

c. Platelet quantitation
- methods:
i.

Direct method
o Reese & Ecker Method
- diluting fluid: sucrose,

diatomite as an activator
o Linearity: 10 seconds
o Normal Value: 75-120
seconds
140-185 seconds (heparin
therapy)
iii.

iv.

Plasma Recalcification Time

o Principle: plasma + Ca++=
clot formation
o Normal Value:
Platelet-poor-plasma 130240 seconds
Platelet-rich-plasma 100150 seconds

c. Common Pathway

(Activated) Partial
Thromboplastin Time
- evaluation of all coagulation
factors except VII and XIII
o Principle: plasma + reagent +
Ca++= clot formation
o Sources of thromboplastin
(lipoprotein) reagent: plants,
rabbits brain, cows brain,
swines brain
o Activators: micronized silica,
elagic acid, kaolin, celite
o Normal Value: 20-45
seconds

b. Extrinsic Pathway
Prothrombin Time
- done on patients with hypertension
- heparin or Coumadin therapy
- test for factor VII activity
o Normal value:
Photo-optical system 10-12
seconds
Manual procedure 12-14
seconds
o Forms of reporting:
PT (Reference range)
PT (Control time)
Prothrombin ratio

% activity
- reference range: 100%
- normal: >85%
- abnormal: <50%
International normalized
ratio (INR)
- 4-digit report
- significant: >2
- normal: <2
- derived PT x international
sensitivity index (ISI)
- agreeable difference = 0.1

i.

Stypven Time/Russells
Viper Venom Test
- factor VII and X deficiency
- direct activation of X to Xa

ii.

Thrombin Time
- tests for levels of
fibrinogen
- I to Ia

iii.

Reptilase Time
- Bothrops atrox
- thrombin-like enzyme
- not affected by heparin

d. Substitution Studies/Mixing Studies

- 5 reagents
Reagent
Fresh plasma
Aged plasma
Adsorbed
plasma
Fresh serum
Aged serum

Contains all factors except

V, VIII
II, VII, IX, X
I, V, VIII, XIII
I, II, V, VIII, XIII

PT =
PT
x 100
CT mean reference range

ERYTHROCYTE ABNORMALITIES
Anemia
- condition associated with decreased hemoglobin,
frequently accompanied by decreased numbers of
red cells in the circulation
- clinical consequence: hypoxia
Types:
1. Absolute
- true decrease in RCM
2. Relative
- fluid shift from the extravascular to the
intravascular compartment
- expanding the plasma volume and diluting the
RCM
- increased plasma volume, normal RCM
Classifications:
1. etiologic
- cause
a. relative anemia
o Pregnancy
o Hyperproteinemia
o Intravenous fluid administration
b. anemia associated with defective
hemoglobin synthesis
o Iron deficiency
Excessive loss
Increased requirement
Deficient intake
Defective absorption
o Sideroblastic anemia
- enzyme that processes heme synthesis
is defective
- iron deposits in the cell
- red cell containing iron store
o Anemia of chronic disease
-defective iron utilization
Infection
Inflammation
Neoplasm
o Thalassemia syndromes
- abnormal globin chains

c. anemia associated with vitamin B12 or folate

deficiency
o Vitamin B12 deficiency
Inadequate dietary intake
Defective absorption
Increased requirement
Defective production of intrinsic
factor
o Folate deficiency (neuronal maturation)
Impaired utilization
Folate antagonism
d. anemia associated with impaired bone
marrow or stem cell dysfunction
o Bone marrow injury
- reduced hematopoietic tissue
Primary aplastic anemia
- idiopathic defect
Secondary aplastic anemia
- injury by drugs, radiation,
chemicals, infectious agents
o Bone marrow replacement
- infiltration with abnormal tissue
Myelophthisic anemia
Myelofibrosis
Leukemia
Lymphoma
Myeloma
metastatic neoplasm
storage disease
o Ineffective hematopoiesis
myelodysplastic anemias
Refractory anemia
Refractory anemia with ringed
sideroblast (RARS)
Refractory anemia with excess
blast (RAEB)
Refractory anemia with excess
blast in transformation (RAEBT)
Chronic myelogenous leukemia
(CML)
o Decreased marrow stimulation
Anemia of renal failure
Anemia of endocrine disorders
Anemia of chronic disease
o Constitutional anemia
- congenital or genetic predisposition to
bone marrow failure
Diamond-Blackfan Anemia

 Fanconi Anemia
Familial Aplastic Anemia
o Acquired pure red cell aplasia
- erythroid marrow suppression
Acute Self-Limited
- associated with viral agents
Thymoma
- immunologic suppression
o Paroxysmal nocturnal hemoglobinuria
(PNH)
- acquired stem cell disorder
e. anemia associated with decreased red cell
survival and increased red cell destruction
f. anemia secondary to blood loss
2. morphologic
- red cell indices and direct examination of their
morphology
Normocytic Normochromic Anemias
- decreased RBC production
*Mechanisms:
o Suppression of production in the
presence of adequate iron stores
- lack of erythropoietin
o Increased turn-over rate
o Acute blood loss
a. Aplastic Anemia/Blood Cell Pancytopenia
- Generalized suppression of the bone
marrow resulting in non-production of
red cells
*Causes:
o Hematopoietic stem cell damage
o Autoimmune mechanisms
o Hematopoietic Inductive
Microenvironment (HIM) of the
bone marrow than cannot support
stem cell growth
*Stages:
o Normocellular
o Hypocellular
o Acellular
*Types:
o Congenital/Familial/Primary

Aplastic Anemia/ Fanconis Anemia

Bone marrow
- hypoplastic
Blood picture
- anisopoikilocytosis
- relative reticulocytosis
(normal: 0.5-1.5%)
- leukoerythroblastosis
Others
- elevated OFT
- elevated ESR
- elevated HbF
o Acquired/Secondary Aplastic
Anemia
- causes:
Physical agents: radiation
Chemical agents: drugs,
benzene and its derivatives
Viral agents: non-A or non-B
hepatitis
Bacterial causes: miliary
tuberculosis, brucellosis
Parasitic agents
Immune-mediated responses:
T cell action
Decreased blood cell counts
PBS
- slight macrocytosis
- absence of immature cells
RPI
- decreased
LAP (alkaline phosphatase)
Score
- increased
HAM Acidified Serum Test
(HAST)
- positive
Serum Iron
- elevated
EPO
- normal/elevated
o Idiopathic Aplastic Anemia
b. Pure Red Cell Aplasia
(PRCA)/Erythroblastopenia
- Absence of red cells only
*Hematologic Findings:
o Severe normocytic normochromic

anemia
o Reticulocyte count
- severely decreased
- as low as zero
o Other hemocyte counts
- normal
o Bone marrow
- essentially normal
*Types:
o Congenital Erythroid Hypoplasia
- Diamond Blackfan Syndrome
- Congenital Hypoplastic Anemia
- manifestations: sexual immaturity,
mental retardation
Hb value (newborn)
- 1.7-9.4 g/dL
- normal: 18-20 g/dL
Normal red cell survival
RPI
- decreased
HbF
- elevated
Bone marrow
- cellular
EPO
- elevated
o Acute Acquired Erythropoietic
Hypoplasia
- Parvovirus B19
- anemia for 1-2 weeks
- giant erythroblasts
o Chronic Acquired Erythrocytic
Aplasia/Chronic Acquired
Erythroblastophthisis
- hemolytic anemia progresses to
aplastic anemia
c. Congenital Dyserythropoietic Anemia
(CDA)/Ineffective Erythropoiesis
*Bone Marrow Characteristics:
o Multinuclearity
o Erythroblastic mitotic figures
- Cabot rings
o Karyorrhexis
- inability of nucleus to form a
circular pattern
o Bizarre malformations in the

erythroblast
*Types:
o CDA-I
Megaloblastic changes with
some binuclearity in
approximately 5% of marrow
erythroblast
Thin internuclear chromatin
bridges that join 2 erythroblasts
that stain Feulgen (+)
Macrocytic anemia
Anisopoikilocytosis
Cabot rings
Basophilic stipplings
o CDA-II/Hereditary Erythroblastic
Multinuclearity with Positive
Acidified Serum Lysis Test
(HEMPAS)
Binuclearity and multinuclearity
of 10-40% of erythroid
precursors
Sucrose hemolysis test (-)
Red cells react with anti-I and
anti-i
Red cell membrane doubling
(phase contrast microscopy)
Normocytic anemia
o CDA-III
- autosomal dominant
More pronounced
multinuclearity (12 nuclei)
Macrocytic anemia
d. Hemolytic Anemias/Anemias of Decreased
Red Cell Survival and Increased Red Cell
Destruction
i.

Due to Intrinsic Red Cell Defects

o Enzyme Deficiencies
Glucose-6-PhosphateDehydrogenase (G6PD)
Deficiency
- hexose monophosphate
shunt/pentose phosphate shunt
- decreased NADPH and GSH
(reduced glutathione) which
reverse the formation of

hemiglobin (contains ferric iron)

- hemiglobin becomes
sulfhemoglobin
- due to drugs and chemicals:
Primaquine,
phenylhydrazine
- polycythemia vera
Nitrofurantoin
- recurrent UTI
Nalidixic acid,
sulfanilamide
- antimicrobial
Methylene blue
- methemoglobin
removal
Naphthalene
- diarrhea
- Heinz bodies (precipitated
globin molecules from
sulfhemoglobin)
Pyruvate Kinase Deficiency
- Embden-Meyerhof Pathway
- decreased ATP
- mild to moderately severe
hemolytic anemia
- shift to the right of the oxygenhemoglobin dissociation curve

o Membrane Defects
Hereditary Spherocytosis
- abnormal vertical arrangement
of spectrin, ankyrin, band 3, and
protein 4.2
- laboratory findings:
Blood film
- numerous
microspherocytes
Reticulocyte count
- increased (>20%)
MCHC
- >36%
OFT
- increased
DAT (-)
Autohemolysis (+)
Hereditary Elliptocytosis
- weakening of the membrane
skeleton
- abnormal horizontal

ii.

arrangement of spectrin dimers,

protein 4.1, and actin
- types:
Common
- pyropoikilocytosis
(sensitive to heat)
- lysis at 45-46C
Spherocytic
Stomatocytic
- laboratory findings:
PBS
- >25% elliptocytes
- normal: 10%
OFT
- normal
Autohemolysis
- normal
Hereditary Stomatocytosis/
Hereditary Hydrocytosis
- absence of stomatin
- common in Rh null individuals
- laboratory findings:
Macrocytic red cells
MCV
- >150fL
OFT (+)
Autohemolysis (+)
Bassen-Kornzweig Syndrome
- abetalipoproteinemia
- acanthocytosis
- disorganized lipoproteins

Due to Extrinsic Red Cell Defects

o Autoimmune Hemolytic Anemia
(AIHA)
- due to autoagglutinins
Warm-antibody AIHA
- 37C
- IgG
- hemolysis in spleen
Cold-antibody AIHA/Cold
Agglutinin Syndrome/Raynauds
Phenomenon
- IgG, anti-I, anti-i bind to red
cells
- IgM
- hemolysis in liver
Drug-induced

- penicillin
Microcytic Hypochromic Anemias
- stibophen (deworming of pigs)
Paroxysmal Cold
Hemoglobinuria
- Donath Landsteiner
Autoantibody
- IgG activated upon exposure
to cold (15C- binding; 37Clysis)
a. Iron Deficiency Anemia
- specific for the P blood group
system
*Stages:
Microangiopathic Hemolytic
o Iron depletion
Anemia (MAHA)/Traumatic
o Iron deficient erythropoiesis
Anemia
o Iron deficiency anemia
- possible associations:
Fibrin deposition (vessel
*Signs and Symptoms:
injury)
o Fatigue
Severe systemic
o Paleness
hypertension
o Unusual cravings (pica)
Vessel abnormalities
o Dizziness
- disorders:
o Nausea
DIC
o Fainting spells
TTP
o Plummer-Vinson Syndrome
HUS
- glossitis, sore mouth, dysphagia
Paroxysmal Nocturnal
Hemoglobinuria
*Laboratory Findings:
- abnormal cloning of bone
o PBS
marrow stem cells
- microcytosis, hypochromia,
- cells demonstrating sensitivity
poikilocytosis (target cells, burr
to complement lysis
cells), anulocytes
- types:
o Reticulocyte Count
PNH I
- normal
- normal reaction to
o Free Erythrocyte Protoporphyrin
complement
(FEP)
PNH II
- increased
- 3-5x susceptibility to
o Platelet count
lysis
- normal to slightly increased
PNH III
o Storage iron
- 15-25x susceptibility to
- absent
lysis
o Serum iron
- decreased
o Total Iron Binding Capacity (TIBC)
- increased
*Treatment: replacement therapy (ferrous
iron)

- 7-10 g/dL
PBS
- dimorphism
- marked anisopoikilocytosis
- red cell fragments
- basophilic stipplings
M:E ratio
- 1:1
- normal= 2/4:1
o Secondary Sideroblastic Anemia
- caused by toxins, chemicals, and
drugs
- common in lead poisoning,
tuberculosis therapy,
chloramphenicol administration,
alcoholism
c. Anemia of Chronic Disease
- defect in iron utilization

b. Sideroblastic Anemia
- iron loading and accumulation in the
mitochondria of erythroid precursors
- excessive accumulation of iron granules in
immature red cells (sideroblast)
*Types:
o Hereditary Sideroblastic Anemia
- heme synthesis defect
- laboratory findings:
Hb
- 6.0 g/dL
PBS
- dimorphism
- basophilic stipplings
- target cells
Bone Marrow
- 10-40% of normoblasts are
sideroblasts
o Primary Idiopathic Sideroblastic
Anemia
- acquired due to abnormal
erythropoietic maturation
- laboratory findings:
Hb

*Causes:
o Chronic infections
o Inflammatory processes
o Malignant neoplasms
*Laboratory Findings:
o TIBC
- decreased
d. Thalassemias
- genetic abnormalities in globin synthesis
- faulty transcription leading to deficient
amount of chains (normal: 4 chains)
*Classifications:
o Beta Thalassemias
Thalassemia Major/Cooleys
Anemia
- homozygous beta thalassemia
- 00 (absence)
- ++ (deficiency)
- retarded growth
- mongolism
- evident in people aged <20
years old
- laboratory findings:
PBS
- microcytosis
- hypochromia
- extreme

anisopoikilocytosis
- fatal to the fetus
- 3+ target cells
because it binds oxygen
- 2+ basophilic stipplings
but does not release it
- 3+ nucleated RBCs
leading to pronounced
Reticulocyte Count
ischemia, heart failure,
- inadequate
and edema
Hb Electrophoresis
- increased nucleated
- hemoglobin Lepore
RBCs
- 2.5-6.5 g/dL
HbH
- HbA1 absent
- small amounts
- HbF decreased
Heterozygous
Thalassemia Minor/Cooleys
- HbH disease
Trait
- HbH: monument appearance/
- heterozygous beta thalassemia
pitted ball appearance
- slight splenomegaly and mild
- Constant Spring disease
anemia
- laboratory findings:
- laboratory findings:
HbH inclusions: 3+
PBS
- 1+ basophilic stipplings
- 1+ target cells
Macrocytic Normochromic Anemias
Hb Electrophoresis
- HbF normal or
Megaloblastic Anemia
increased
- 10-12 g/dL
*Causes:
Thalassemia Intermedia
o Vitamin B12 or folate deficiency
- mild form of homozygous beta
- causes:
thalassemia
Inadequate dietary intake
- moderate anemia
Defective absorption
- laboratory findings:
Increased requirements
PBS
Defective production of intrinsic
- 1+ basophilic stipplings
factor
- 2+ target cells
Impaired utilization
Hb Electrophoresis
- 6-10 g/dL
Vitamin B12
Folate
(mcg)
(mcg)
o Alpha Thalassemias
Liver Stores
1000
5000
- reduced or abnormal alpha chain
Daily Intake
1-5
50-500
synthesis
Daily Loss
1-2
50-100
- 0 (absence)
- + (deficiency)
o Drugs that interfere with DNA
- may form HbH or Barts Hb
metabolism
Homozygous
o Decreased thymidine triphosphate
- Hydrops Fetalis Syndrome
o Prolonged intermitotic resting phase
- thalassemia-1-trait
- laboratory findings:
*Types:
Barts Hb/Hemoglobin
o Pernicious Anemia
Barts Hydrops Fetalis
- autoimmune disease
- 80%
- test: Schillings Test (uses
- exists in utero

radioactive cobalt)
- laboratory findings:
MCV
- 110-130 fL
PBS
- pancytopenia
- macro-ovalocytes
- hypersegmented neutrophils/
macropolycyte
- nucleated RBCs exhibit
karyorrhexis
Haptoglobin
- decreased
Methemalbumin
- increased
Intravascular hemolysis
o Celiac Disease
- malabsorption syndrome
- sensitivity to gluten (wheat)
- atrophy of proximal portion of the
small intestines
o Tropical Sprue
- idiopathic
- intestinal atrophy

of erythropoietin (EPO)
*EPO
- growth factor from the kidney that stimulates
the production of red cell
Mechanisms:
a. acts on marrow to increase the number
of erythroid precursors
b. increases the rate of RBC proliferation
and maturation
c. accelerates the release of RBC from the
bone marrow
*Maturation sequence (18-21 days):
Totepotent hematopoietic stem cell
CFU-E 1 week
BFU-E 1 week
Pronormoblast 1 day
Basophilic normoblast 1 day
Polychromatophilic normoblast 1 day
Orthochromic normoblast- 2 days
Polychromatophilic erythrocyte- 2 days
Erythrocyte
Hematocrit

3. physiologic
- ability of the bone marrow to respond to anemia
with increased erythropoiesis
Physiologic Responses to Anemia:
1. Chemical and Physical Response
- anemia results in the reduction of oxygencarrying capacity of blood
- compensation:
a. increase in 2,3-DPG
- transient molecule that occupies the
central oxygen area of hemoglobin forming
the relaxed form of hemoglobin and
allowing easier release of oxygen
- shift to the right
b. selective redistribution of blood flow to
areas of highest oxygen demand (brain)
c. increase in cardiac output

0.40-0.45
0.35-0.39
0.25-0.34
0.15-0.24
<15

Maturation Time
(Days)
1.0
1.5
2.0
2.5
3.0

Failure to Respond:
1. intrinsic disease
- decreased vitamin B12 absorption which is
important for erythropoiesis
2. lack of hematopoietic factors
- iron deficiency leading to impaired heme
synthesis
3. failure in erythropoietic mechanism
- damaged kidneys supposedly compensated by
extramedullary erythropoiesis (liver and spleen)

2. Hematologic Response
- tissue hypoxia is detected by the peritubular
capillaries in the kidneys leading to increased
erythropoietic marrow stimulation by the release

Clinical Manifestations:
1. mild anemic states
- no signs and symptoms
2. palpitations and dyspnea (shortness of breath)
during exercise
3. increasing severity
- cardiac stress, tachycardia, dyspnea, frequent
headaches
4. pallor
- paleness due to selective redistribution of blood
5. secondary to hypoxia
- cramps, dizziness, fatigue, insomnia
6. most severe form
- coma, death

Mechanism:
a. kidney hypoxia leading to EPO release
b. tumor releases substances that mimic
EPO stimulating the bone marrow to
produce RBCs
c. tumors stimulate the production of EPO
by the kidneys
Diagnosis:

Erythrocytosis and Polycythemia

- conditions involving the presence of too many
red cells in the circulation
- increased red cell mass (RCM)
- hematocrit level above the established reference
range
- primary clinical consequence: expanded blood
volume and increased blood viscosity
Pathophysiology:

Classifications of Erythrocytosis:

1. Primary Erythrocytosis/Polycythemia Vera

1. Absolute Erythrocytosis
- caused by chronic myeloproliferative disorders - true increase in RCM
leading to the uncontrolled production of all cell
types
a. Absolute Primary Erythrocytosis
(+) Effect: increased blood volume,
- results from a clonal, pluripotent stem cell
vasodilation, enhanced blood
disorder
perfusion and tissue oxygenation
- erythrocyte production is not controlled by
EPO level
(-) Effect: hyperviscosity, slow blood flow,
*Erythremia
Thrombosis
- clonal disorder which exclusively affects
red cell production in the bone marrow
2. Secondary Erythrocytosis
- arises from pre-existing health conditions
b. Absolute Secondary Erythrocytosis
Appropriate Response
- release of EPO from the kidney in
response to hypoxia
Inappropriate Response
- generation of EPO without hypoxia due to
tumors in the renal artery

Appropriate
Monges Disease/Chronic Mountain
Sickness
- lungs of highlanders have a
difficult time coping to the relatively
low oxygen tension in lowlands

- high hematocrit and oxygen

tension
Pulmonary Disease (Chronic
Obstructive Pulmonary Disease/
COPD)
- leading cause of death among
smokers
- thickening and crusting of
alveolar sac
- impaired deflation of the sac
- decreased hemoglobin levels

Cardiovascular Disease
- decreased heart function leads
to delayed oxygenation

Alveolar Hypoventilation
- impaired respiration due to
obesity and mechanical
obstruction in the upper
respiratory tract

Hemoglobinopathy
- shift to the left
*Hemoglobin Chesapeake
- hemoglobin compounds
that bind oxygen but dont
release it
*Methemoglobinemia
Tobacco Smoking
- dehydration
Carboxyhemoglobinemia
- hemoglobin has 200 times
more affinity to carbon
monoxide than to oxygen
- renders hemoglobin nonfunctional

Extrarenal Tumors
- brain, liver, ovary, uterus,
prostate, thymus, adrenal glands
- transient hypoxia which is
unnecessarily addressed

Essential/Idiopathic Origin

2. Relative Erythrocytosis
- results from the decrease in the plasma volume
- decreased plasma volume, normal RCM
Causes:
a. dehydration
b. anxiety/stress
- Gaisbocks Syndrome
c. smoking associated/tobacco
polycythemia
Tests:
1. Red Cell Mass (RCM) Determination
- radioisotopic dilution techniques
- men: >36 mL/kg
considered
- women: >32 mL/kg
excessive
2. Radioimmunoassay (RIA)
- EPO: primary erythrocytosis (PE)
- normal or EPO: secondary erythrocytosis (SE)
3. Arterial Blood Gas Analysis (SO2)
- normal: 92% PE
- : SE
4. Oxyhemoglobin Dissociation Curve (P50)
- : non-functional hemoglobin with increased O2
affinity; shift to the left
5. Electrophoresis

o Inappropriate
6. CT Scan/MRI

Renal Disorder
- tumor interfering with renal
perfusion
- EPO-like substance is released
- kidney transplant

LEUKOCYTE ABNORMALITIES
Leukemia
- Uncontrolled malignant proliferation of WBC
present in the bone marrow and in peripheral blood
- Definitive cause is unknown
*Risk factors:
a. Genetic predisposition
b. Exposure to agents like chloramphenicol,
radiation, benzene and its derivatives
c. Immunosuppression
*Signs and symptoms:
a. Pallor
b. Anorexia
c. Palpitation
*Pathophysiology of Leukemia: Bone Marrow
Failure

Acute Leukemias
1. Acute Myelogenous Leukemia (AML)
- most common leukemia in the first months
of life
- FAB classification: >30% of all nucleated
cells in the bone marrow are myeloblasts
- WHO classification: >20% of all
nucleated cells in the bone marrow are
myeloblasts
- Auer rods are mostly in myeloblasts and
promyelocytes
- cells with bundles of Auer rods are called
Faggot cells
- cytochemical staining:

*Classifications According to FAB (French,

American, British Association)
1. According to course of disease
a. Acute: <3-6 months; immature cells
b. Sub-acute
c. Chronic: >6 months; mature cells
2. According to cell type
a. Myelocytic, monocytic, erythrocytic
b. Lymphocytic, plasmacytic
3. According to blood picture
a. Leukemic
b. Sub-leukemic
c. Aleukemic

a. M0: Myeloblastic Leukemia with

Minimal Differentiation
- myeloid associated antigens:
o MPO
o CD13
o CD117
- Criteria for diagnosis:
o Non-granular blasts
o <3% are MPO (+) by enzyme
cytochemistry
o Blasts express myeloid antigens but
not classic lymphocyte antigens

o Blasts may abnormally express

some lymphocyte antigens
b. M1: Myeloblastic Leukemia without
Maturation
- criteria for diagnosis:
o At least 90% of non-erythroid cells
are myeloblasts
o At least 3% of blasts must be
MPO/SBB (+)
o Very immature cells usually round
with few granules or Auer rods
o Little maturation beyond myeloblast
stage
c. M2: Myeloblastic Leukemia with
Maturation
- most common type of AML
- easy to diagnose
- criteria for diagnosis:
o 20-89% of non-erythroid cells are
myeloblasts
o Full range of myeloid maturation
through granulocytes
o Auer rods usually present
o Maturing neutrophils, erythroid, and
megakaryocyte precursors may have
dysplastic change
o 70% of patients have Auer rods
o MPO/SBB (+)
d. M3: Hypergranular Promyelocytic
Leukemia
- most commonly associated with DIC
- criteria for diagnosis:
o Most cells (>50%) are abnormal
promyelocytes with heavy
cytoplasmic granulation, often with
reniform nucleus
o Cells with multiple Auer bodies
usually present
o Most cells are hypergranular
promyelocytes with heavy red/
purple cytoplasmic granulation
e. M3v: Microgranular Promyelocytic
Leukemia
- criteria for diagnosis:
o Distinct Auer rods

o Microgranular promyelocytes
f. M4: Myelomonocytic Leukemia/
Naegelis Leukemia
- often with markedly elevated WBC,
organomegaly, lymphadenopathy and
other tissue infiltration by monocytes
- criteria for diagnosis:
o Myeloblasts and monoblasts are
20% or more of non-erythroid cells
o 60% of patients have Auer rods in
myeloblasts
o >20% of ANC (absolute neutrophil
count) SBB/POD (+)
o >20% of ANC aNAE/aNBE (+)
g. M4E: Myelomonocytic Leukemia with
Eosinophilia
- diagnostic features are similar with M4
but with the presence of eosinophilia
h. M5: Monocytic Leukemia/ Schillings
Leukemia
- higher incidence in older patients
- presents with a greater extent of
organomegaly, lymphadenopathy, and
tissue infiltration
- criteria for diagnosis:
o 80% or more non-erythroid bone
marrow cells belong to the
monocytic lineage
o >80% ANC are aNAE/aNBE (+)
- types:
o M5A: Monocytic Leukemia without
Maturation
o M5B: Monocytic Leukemia with
Maturation
i. M6: Erythroleukemia/ DiGuglielmos
Leukemia
- criteria for diagnosis:
o 50% or more of ANC are
erythroblasts
o 20% or more of non-erythroid cells
are myeloblasts
o Dyserythropoiesis is prominent
o PAS (+)
j. M7: Megakaryoblastic Leukemia
- associated with marrow fibrosis due to

megakaryoblast secretion of fibrogenic

cytokines
WHO Classifications
- peripheral blood often contains
micromegakaryocytes and atypical
a. ALL (L1, L2)
platelets
b. Burkitts Lymphoma (L3)
- often mistaken as Paris-Trousseau
c. Pre-B ALL
Syndrome
d. Pre-T ALL
- criteria for diagnosis:
e. Biphenotypic Acute Leukemia
o 20% or more blasts are present in
the bone marrow
Chronic Leukemias
o Megakaryoblasts are medium/large - common in individuals aged 40-60 years old
cells with dense chromatin, blue
- enlarged lymph nodes
vacuolated cytoplasm, fine granules, - WBC 30-200x109/L
cytoplasmic projections resembling
platelets
1. Chronic Granulocytic Leukemia (CGL)
a. Chronic Myelogenous Leukemia
2. Acute Lymphoblastic Leukemia (ALL)
b. Chronic Eosinophilic Leukemia
- most common of all leukemias
c. Chronic Myelomonocytic Leukemia
- best prognosis
- signs and symptoms:
2. Chronic Lymphocytic Leukemia
o Hepatosplenomegaly
- positive for lymphocytic antigens
o CNS damage
- diagnostic feature: smudge cells
o Infiltration of the scrotum in children
- organ involvement:
Other WBC Dyscrasias
o Spleen
o Liver
1. Hairy Cell Leukemia/ Leukemic
o Scrotum
Reticuloendotheliosis
- manifestations:
- Hairy cells:
o Anemia
o 12-20 microns
o Thrombocytopenia
o Round to oval nucleus
9
o WBC >100x10 /L
o Cytoplasm has fine filamentous
- blood picture:
projections arising from the
o Blast cells
membrane
o Atypical lymphocytes (without increase
- leukemic cells stain tartrate resistant acid
in cytoplasm)
phosphatase/TRAP (+)
- terminal deoxynucleotidyl transferase/
TDT (+)
2. Plasma Cell Dyscrasias
- rouleaux formation
FAB Classifications
- increased plasma proteins
a.
b.
c.
d.

Multiple myeloma
Plasma cell leukemia
Waldenstrms macroglobulinemia
Heavy chain disease

Lymphoma
- malignant tumors of lymphoid tissues
1. Hodgkins Lymphoma/
Lymphogranulomatosis
- Reed-Sternberg cells
2. Non-Hodgkins Lymphoma
3. Other Lymphomas
a. Sezary Syndrome
- caused by Mycosis fungoides
- nucleus has brain-like convolutions
b. Burkitts Lymphoma
- caused by Epstein-Barr Virus (EBV)
- starry sky appearance
c. Lymphoplasmacytic Lymphoma