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Hematology Greek:
-Haima = Blood
-Logos = Study/science
EDTA Chelates calcium
(Lavender top) Inversion: 8x
Anticoagulant of choice for hematology cell counts and cell
morphology
Blood smear: prepare w/in 2 hrs
Preferred anticoagulant for platelet count:
= In some patients w/ EDTA anticoagulated blood – platelet
satellitism
= Platelet satellitism: platelets adhere to neutrophils
♫ Effect to automated platelet count = Decreased
♫ Remedy: Repeat platelet count using citrate (Rodak: Platelet
count x 1.1)
EDTA = Shrinkage of cells = Hct = ESR
Not for coagulation tests:
= Inhibits fibrinogen-thrombin reaction
= Factor V is not stable in EDTA
Modified 2mL EDTA + 0.5mL NSS/Citrate
Westergren ESR Ratio = 1:4 (Anticoagulant-to-Blood)
(Black top tube)
Citrate For coagulation and platelet studies
(Light blue top = Preserves labile factors V and VIII
tube) = Buffered 3.2% (0.109M) citrate
Inversion: 3-4x
Ratio = 1:9 (Anticoagulant-to-Blood)
Polycythemic Hct
patients Excess Citrate = PT, APTT
Remedy: Reduce the volume of citrate
Amount of citrate = [(100-Hct)÷(595-Hct)] x mL WB
Oxalate Double/balanced oxalate (Ratio = 2:3): Maintained cell
structures
a. Potassium oxalate (Paul-Heller’s) = shrink cells
b. Ammonium oxalate (Wintrobe’s) = swell cells
Heparin Inactivation of thrombin
Anticoagulant for osmotic fragility test
Inversion: 3-4x
Not for blood film preparation:
= Distorts cells
= Produces bluish background on Romanowsky’s stain
Not for coagulation
= Inhibits thrombin and all stages of coagulation
Order of Draw Evacuated tube:
(Henry 21st Edition) 1. Sterile blood culture tube
2. Citrate (blue)
3. Nonadditive tube (red)
4. Heparin (green)
5. EDTA (lavender)
6. Fluoride (gray)
Order of Draw 1. EDTA
(Syringe method) 2. Other anticoagulated tubes
3. Nonadditive tube
EDTA containing Lavender
tubes Pink
White
Royal blue
Tan
Skin puncture 1. Fingertips
2. Earlobe: less admixture w/ tissue juice, less pain, less free
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nerve endings
3. Lateral portion of the plantar surface of the foot: <1
year old
Difference from venous specimen:
WBCs
Hgb, Hct, RBCs, platelet
Venipuncture Veins in the arms (antecubital region):
1. Median cubital = preferred, most stable
2. Cephalic (lateral)
3. Basilic (medial)
Common gauge 19, 20, 21
(needle) Routine: 20g
Common length of 1-1.5 inches
needle
Color coded hub 18 = pink
(gauge) 21 = green
22 = gray
23 = blue/light blue/turquoise
25= orange
Angle Venipuncture: 150
BB: 450 10-200 once in the skin
Tourniquet 3-4 inches above the site (7.5-10cm)
Not exceed 1min/2mins
Prolonged application hemoconcentration
BP cuff as 40-60 mmHg
tourniquet
Reassure the Crying = cell count
patient
Position the patient Lying down = hemodilution ( PCV by 8%, WBC)
Lying up = hemoconcentration
IV line Collect on the other arm
If both arms: Stop IV for 2mins
= Collect blood below the IV line
= Appropriate for all analytes except glucose and phosphorus
Hematopoiesis Cellular formation, proliferation, differentiation and maturation
of blood cells
Mesoblastic period 19th day of gestation
Yolk salk = Erythropoiesis
Embryonic hemoglobins:
a. Gower 1 = Zeta2 + Epsilon2
b. Portland = Zeta2 + Gamma2
c. Gower 2 = Alpha2 + Epsilon2
Hepatic period 3rd month of gestation
Fetal liver = Granulopoiesis, Erythropoiesis, Megakaryopoiesis
Spleen, thymus, lymph nodes
Hemoglobin production:
a. HbF = Alpha2 + Gamma2
b. HbA1 = Alpha2 + Beta2
c. HbA2 = Alpha2 + Gamma2
Myeloid period Between 5th & 6th month of gestation persist throughout
life
BM = 1’ source of cell production (Hematopoiesis)
Sternum = principal source of hematopoiesis in adults
Adults HbA1 = ≥95%
HbA2 = 1.5-3%
HbF = <2%
Neonates HbF = 60-80%
HbA = 20-40%
Marrow specimens 1. Trephine (Core) Biopsy
= Trephine biopsy needle (Jamshidi needle)
2. Aspiration
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= Aspiration needle (University of Illinois sterna needle)
Posterior iliac crest Safest site for BM aspirate/biopsy
M:E ratio Numeric expression comparing the relative number of
granulocytic precursors w/ the relative erythroid precursors in
the BM
NV = 2:1 to 4:1 (Ave. 3:1)
Infection = 6:1
Leukemia = 25:1
Neutrophilic, Eosinophilic, Basophilic precursors = Myeloid
Erythroid precursors
Monocytic precursors = not included
BM Cellularity Percentage of marrow space occupied by hematopoietic cells
compared w/ fat
Normocellular marrow (Adult): 30% - 70% hematopoietic cells
♫ Fat = 10-50%
♫ Hematopoietic elements = 40-60% (Ave. 50%)
Yellow BM Fats
Red BM Hematopoietic cells
Marrow differential Recommended that at least 500, preferably 1000 cells be
counted for a marrow differential
Metamyelocyte/Juve Predominant cell (WBC) in adult BM (up to 32%)
nile granulocyte
Stem cells <1% cells in BM
Osteoblasts Bone forming cells
Confused w/ plasma cells
Waterbug or comet appearance
Osteoclasts Bone destroying cells
Confused w/ megakaryocytes
CD2, CD3 T cells
CD19, CD20 B cells
CD34 Stem cell marker (lymphoid and myeloid precursor)
CD16, CD56 NK cells
CD10 CALLA (Common ALL Antigen)
Erythropoietin Produced by the kidney
Primary regulator of erythropoiesis
Thrombopoietin Produced by kidney and liver
Regulator of thrombopoiesis
Erythropoiesis
Erythropoiesis 1’ stimulus = Hypoxia
IL-3 Multi-CSF (Colony Stimulating Factor)
Stimulates hematopoietic cells
1. Pronormoblast Proerythroblast/rubriblast
N/C ratio = 8:1
Nucleoli = 1-2
Can produce up to 16 RBCs per 1 pronormoblast/rubriblast
2. Basophilic Prorubricyte
normoblast Intensely basophilic cytoplasm
N/C ratio = 6:1
Nucleoli usually not visible
3. Rubricyte
Polychromatophilic Blue-gray to pink-gray cytoplasm
normoblast Last stage capable of mitosis
1st: Hgb synthesis (1st: PCPNB Reticulocyte: Last)
N/C ratio = 4:1
4. Orthochromic Metarubricyte
normoblast Small pyknotic nucleus (dark, small, nonfunctional)
N/C ratio = 1:2
5. Reticulocyte Polychromatophilic erythrocyte/Diffusely basophilic erythrocyte
Romanowsky stain = Polychromasia
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Supravital stain = (+) Fine reticulum of RNA
6. Mature RBC Discocyte
6-8 μm in diameter
Life span: 120 days
3-5 days BM: Pronormoblast Reticulocyte
1-2 days PB: Reticulocyte RBC
General Cell Maturation Characteristics for Leukocytes
Immature Cells Mature Cells
Larger Smaller
(+) Nucleoli (-) Nucleoli
Chromatin: fine and delicate (most reliable) Chromatin: coarse and clumped (most
reliable)
Nucleus: large and round Nucleus: round. lobulated or segmented
Cytoplasm: dark blue/basophilic (RNA) Cytoplasm: light blue (RNA)
(-) Granules (+) Granules
N:C ratio N:C ratio
Granulopoiesis
Granulopoiesis Neutrophils
Eosinophils
Basophils
14 days Blast Mature granulocyte
1. Myeloblast Earliest recognizable stage in granulocytic series
N/C ratio = 4:1
Nucleoli = 2-5
2. Promyelocyte 1st: Primary granules
N/C ratio = 2:1 to 3:1
Nucleoli = 2-3
3. Myelocyte Youngest cell in the series wherein a granulocyte can be
identified
a. Neutrophil myelocyte = rose pink granules
b. Eosinophil myelocyte = orange-red granules
c. Basophil myelocyte = dark purple or blue-black granules
Last stage capable of mitosis
1st: Secondary granules
N/C ratio = 1:1
(-) Nucleoli
4. Metamyelocyte Juvenile granulocyte
Not capable of mitosis (post-mitotic pool)
Indented/kidney-shaped nucleus
Predominant WBC in BM
5. Band Stab/Staff
Youngest cell in the series present in the peripheral blood
(normal)
PB = 0-6% or 0-7%
C or S shaped nucleus
Curved or Sausage shaped nucleus
Resembles Pelger-Huet cells
= PH cells: coarser chromatin than stab cells
6a. Segmented Rose-pink granules
neutrophil Nucleus: 2-5 lobes
Diurnal variation (PM)
Specific granules:
a. Lysozyme
b. Lactoferrin
c. Collagenase
d. Plasminogen activator
e. Aminopeptidase
6b. Eosinophil Reddish-orange granules
Nucleus: usually 2 lobes
Diurnal variation (ACTH)
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Specific granules:
[Larger]
a. Major basic protein
b. Acid hydrolase
c. Cathepsin
d. Eosinophil cationic protein
d. Eosinophil-derived neurotoxin
e. Eosinophil protein X
f. Phospholipase
[Smaller]
a. Arylsulfatase
b. Acid phosphatase
6c. Basophil Dark purple to blue-black granules (water-soluble)
Nucleus: generally unsegmented or bilobed (rare: 3 or 4)
Specific granules:
a. Histamine
b. Heparin
c. Eosinophilic chemotactic factor A
Monopoiesis
Monopoiesis 1. Monoblast
2. Promonocyte
3. Monocyte
Monocyte Largest cell in PB
14-20 μm in diameter
Blue-gray cytoplasm
Many azurophilic granules (ground glass appearance)
Nucleus: kidney/horse-shoe shaped, may be folded (brainlike)
Lymphopoiesis
Lymphopoiesis 1. Lymphoblast
2. Prolymphocyte
3. Lymphocyte
Lymphocyte Small = 8-10μm (Size = RBC)
Medium = 10-12μm
Large = 12-16μm (Rare)
Cytoplasm: bluish (Robin’s egg blue)
Nucleus: compact
T lymphocytes 60-80%
Long-lived (4-10 years)
B lymphocytes 10-20%
Short-lived (3-4 days)
Can differentiate into plasma cell or memory B cells
Null lymphocytes Large granular lymphocyte
10%
Plasma cells 1. Plasmablast
differentiation 2. Proplasmacyte
3. Plasmacyte/Plasma cell
Plasma cell Large well-defined hof/perinuclear halo (light staining area in the
cytoplasm near the nucleus)
Eccentric nucleus
Deeply basophilic cytoplasm (Red/pink cytoplasm: Flame cell
[Abnormal])
Chromatin: “Cart wheel pattern”
Thrombopoiesis
Thrombopoiesis 5 days (Megakaryoblast Platelets)
1. Megakaryoblast N/C ratio = 10:1
2. Nucleus: may show slight lobulation (Endomitosis)
Promegakaryocyte N/C ratio = 4:1 to 7:1
3. Granular
megakaryocyte Largest cell in BM
4. Mature Cytoplasm contains coarse clumps of granules aggregating into
megakaryocyte little bundles, which bud off from the periphery to become
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platelets
Multiple nuclei
N/C ratio = <1:1
5. Disintegrated cell surrounded by platelet
Metamegakaryocyt
e
6. 1-4μm in diameter
Platelet/Thrombocy Light blue to purple
te Very granular
a. Chromomere: granular and centrally located
b. Hyalomere: surrounds the chromomere, nongranular and
clear to light blue
Life span: 8-11 days
2/3 (67%) Circulating platelets
1/3 (33%) Platelets stored in the spleen
Endomitosis Nuclear division w/o cytoplasmic division
2000-4000 # of platelets a megakaryocyte can produce
1 heme molecule 1 mol O2
1 hemoglobin 4 mol O2
Mitochondria Early and late heme synthesis
141 amino acids Alpha
146 amino acids Beta, Gamma, Delta, Epsilon, Zeta
Chromosome 11 Alpha, Zeta
Chromosome 16 Beta, Gamma, Delta, Epsilon
Oxyhemoglobin Normal = Sigmoid in shape
Dissociation Curve X-axis = Hgb concentration in g/dL | Y-axis = OD
Shift to the left CO2
(ODC) Temperature
2,3-DPG
pH
Affinity of Hgb for O2
HbF
Shift to the right CO2
(ODC) Temperature
2,3-DPG
pH
Affinity of Hgb for O2
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Ineffective erythropoiesis (pancytopenia)
Vitamin B12 (Cobalamin) ♫ w/ CNS problems
deficiency 1. Pernicious anemia
= Deficient in intrinsic factor (produced by parietal cells)
for B12 absorption
2. D. latum infection
3. Vegetarian diet
4. Malabsorption syndrome
= Steatorrhea, sprue
Folic acid (Vit. B9) ♫ w/o CNS problems
deficiency 1. Pregnancy
2. Dietary deficiency
3. Steatorrhea, sprue
Polychromasia Reticulocytosis
Visible on Wright’s stain
Blue-gray coloration, pink cytoplasm
Indicates young RBCs
Erythropoietic activity
a. Hemorrhage
b. Hemolysis
Spherocytosis EOFT
Microcytic, hypochromic EOFT
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RBCs s
Nuclear Abnormalities
Pelger-Huet Hyposegmentation (neutrophil)
Bilobed nucleus: Dumb-bell shaped/spectacle/peanut-
shaped/”Pince-nez”
Resembles Stab cell (To differentiate: PH cell has more
clumped chromatin)
♫ Pelger-Huet anomaly = Autosomal Dominant
♫ Pseudo-Pelger-Huet = Acquired in myeloproliferative
disorders
Hypersegmentation ≥ 6 lobes (neutrophil)
Abnormal DNA synthesis
♫ Undritz anomaly = hereditary hypersegmentation
♫ Megaloblastic anemia
Cytoplasmic Abnormalities
Alder-Reilly granules Large purple-black coarse cytoplasmic granules
Accumulation of degraded mucopolysaccharides (all
leukocytes)
♫ Alder-Reilly anomaly = Autosomal Recessive
♫ Mucopolysaccharidoses: Hurler, Hunter, Sanfilippo
syndrome
Resemble toxic granules (IT)
Toxic granules Large purple to black granules resembling ALR granules
♫ Infections
♫ Toxic states
Toxic vacuoles Infections
Toxic states
Auer rods Pink or red rod shaped structures
Fused primary granules (peroxidase positive)
Myeloid and monocytic series only
Faggot cells w/ mass of Auer rods
M3 (APL) = associated w/ DIC
Chediak-Higashi granules Giant red, blue to grayish round inclusions (large
lysosomal granules)
Seen in lymphocyte, neutrophil and monocyte
Lysosomal defects
Platelets lack dense granules
♫ Chediak-Higashi syndrome = Autosomal Recessive
(Albinism)
May-Hegglin inclusion Pale blue inclusions derived from RNA
♫ May-Hegglin anomaly
= Autosomal Recessive
= Giant platelets
= Thrombocytopenia
Resemble Dohle bodies (IT)
Dohle bodies Single or multiple blue inclusions
Dohle-Amato bodies Aggregates of free ribosomes of rough ER
Resembles
♫ Infections
♫ Toxic states
IT: Infections, Toxic states Dohle bodies
Toxic granules
Toxic vacuoles
Abnormalities in Function
Job’s syndrome Normal random activity
Abnormal chemotactic activity
Lazy leukocyte syndrome Abnormal random and chemotactic activity
Chronic Granulomatous Inability of phagocytes to kill ingested microorganisms
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Disease (CGD) Impaired NADPH oxidase
Impaired oxidative metabolism/respiratory burst
Test: NBT dye test
Cells Exhibiting Phagocytosis
LE cell Neutrophil w/ large purple homogeneous round inclusion
Believe to be a neutrophil that ingested another
neutrophil
Buffy coat
Smooth and evenly stained
♫ SLE
Tart cell Monocyte w/ ingested lymphocyte
Rough and unevenly stained
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Dutcher’s bodies Intranuclear protein inclusions
Platelet Abnormalities (Morphologic)
Giant platelet ♫ Bernard-Soulier syndrome
♫ May-Hegglin anomaly
Small/micromegakaryocyte ♫ Myelodysplastic syndromes
Large megakaryocyte
Mononuclear
megakaryocyte
Vacuolated megakaryocyte
Leukemia
Leukemia Abnormal, uncontrolled proliferation and accumulation
of one or more of the hematopoietic cells
Symptoms: Fever, weight loss, sweating;
hepatosplenomegaly, enlarged lymph nodes (chronic
leukemia)
BMR
Acute leukemia Days to 6 months
Predominantly immature cells (blasts and “pro” stages)
Subacute leukemia 2 to 6 months
Chronic leukemia Variable
Minimum of 1 or 2 years
Predominantly mature cells
Leukemic leukemia WBC >15,000/μL
Subleukemic leukemia WBC <15,000/μL
(+) Abnormal and immature cells in PB
Aleukemic leukemia WBC <15,000/μL
(-) Abnormal and immature cells in PB
French-American-British Divides acute leukemias into lymphoblastic and
(FAB) Classification of monoblastic
Acute Leukemias = Subdivided according to cellular morphology,
cytochemical staining results, cytogenetic studies and T
& B lymphocytes marker results
Acute leukemia Normocytic, normochromic RBCs
FAB = ≥30% blasts
Henry: WHO (Now the standard for diagnosis) = ≥20%
Acute leukemia in children 80% ALL
20% ANLL
Tests to differentiate ALL 1. MPO: Myeloperoxidase
from ANLL = (+) AML
= (-) ALL
2. SBB: Sudan Black B
= (+) AML
= (-) ALL
3. TdT: Terminal Deoxyribonucleotidyltransferase
= Marker for immature lymphocyte
= (+) ALL
= (-) ANLL
Acute Lymphoblastic Leukemias (ALL)
L1 Lymphoblasts are small and homogeneous (vary little in
size)
Childhood ALL
L2 Lymphoblasts are large and heterogeneous (vary in
size)
Adult ALL
L3 Burkitt-type
Rare
Lymphoblasts are large but homogeneous, and
vacuolated
Acute Nonlymphocytic Leukemias (ANLL)
M1 Acute myeloblastic leukemia w/o maturation (AML w/o
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mat)
BM:
>30% blasts
<10% granulocytic cells
M2 Acute myeloblastic leukemia w/ maturation (AML w/
mat)
BM:
>30% blasts
>10% granulocytic cells
M3 Acute promyelocytic leukemia (APL)
>30% blasts
>10% granulocytic cells
>30% or >50% promyelocytes
(+) Faggot cells = Associated w/ DIC
M4 Acute myelomonocytic leukemia (AMML)
Naegeli’s leukemia
20% to <80% monocytic cells
M5a Acute monoblastic leukemia w/o maturation
Schilling’s leukemia
>80% monocytic cells (>80% monoblasts)
M5b Acute monoblastic leukemia w/ maturation
>80% monocytic cells (<80% monoblasts)
M6 Erythroleukemia
Erythremic myelosis
Di Guglielmo’s syndrome
>30% blasts
>50% erythrocytic precursors
M7 Acute megakaryocytic leukemia
>30% blasts
>30% megakaryocytic cells
Chronic Myeloproliferative Disorders
MPD Proliferation of abnormal pluripotential stem cell
Stem cell differentiates into the granulocytic (myeloid
stem cell), megakaryocytic and erythroid cell lines
1. Chronic Myelogenous (+) Philadelphia chromosome: t(9+;22-) - both long arms
Leukemia (CML) If (-) Ph’ chromosome = poor prognosis
Similar to leukomoid reaction, to differentiate:
a. Chromosome studies
b. LAP = ( in Leukomoid reaction, in CML)
2. Myelofibrosis w/ myeloid Fibrosis and granulocytic hyperplasia of BM, w/
metaplasia (MMM) granulocytic and megakaryocytic proliferation in the
liver and spleen (extramedullary)
(+) Dacryocytes
LAP
BM aspirate = impossible (dry tap)
BM biopsy = appropriate
3. Essential Thrombocytosis: 1,000 x 109/L
Thrombocythemia (ET) Functionally abnormal platelets
4. Polycythemia Vera (PV) BM: Panmyelosis
PB: Pancytosis/Pancythemia
RBCs, WBCs, Plts
LAP (Other polycythemia: N-LAP)
Polycythemia
1’ Absolute polycythemia Other names: Polycythemia Vera, Polycythemia
Rubravera, Vaquez Osler disease, Panmyelosis
RBC mass ( Hct)
RBCs, WBCs, Platelets
Erythropoietin (EPO)
2’ Absolute polycythemia In response to hypoxia
w/ appropriate production In patients w/ pulmonary/cardiac disease
of EPO RBCs, WBCs, Platelets
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EPO
2’ Absolute polycythemia In patients w/ tumors of kidney, liver, brain, adrenal and
w/ inappropriate pituitary gland
production of EPO RBCs, N-WBCs, N-Platelets
EPO
Relative polycythemia Spurious/Gaisböck polycythemia
Associated w/ stress and anxiety
N-RBC mass
Hct because of decreased plasma volume
RBC mass Differentiate absolute from relative polycythemia
RBC mass = Absolute polycythemia
N-RBC mass = Relative polycythemia
Myelodysplastic Syndrome/Dysmyelopoietic Syndrome
MDS Clonal abnormalities in hematopoietic cells
“Pre-leukemia”: can progress to ANLL if not treated
<30% blast
Differentiation % Blasts in PB % Blasts in BM Comments
Refractory anemia <1% <5% Mildest type
(RA)
RA w/ ringed sideroblast <1% <5% RS: Ringed
(RARS) >15% RS sideroblast
RA w/ excess blast <5% 5-20%
(RAEB)
RAEB in transformation >5% 20-30%
(RAEBt)
Chronic Myelomonocytic <5% 5-20% Persistent
Leukemia (CMML) monocytosis
Lymphoproliferative disorders
LPD Proliferation of cells derived from lymphoid stem cell
T/B cells
1. T/B cell leukemia --
2. Lymphoma Malignancy involving lymphoid tissue
a. Non-Hodgkin’s lymphoma
= proliferation of neoplastic lymphocytes
= Rappaport classification
b. Hodgkin’s lymphoma
= proliferation of cells reacting to neoplasm
= (+) Reed-Sternberg cell: large cell w/ large nucleoli
(Owl’s eye)
♫ Diagnosis: Lymph node biopsy
= Rye classification: based on histologic appearance of
lymph node biopsy
= Ann-Arbor: staging based on the extent of tissue
involved
3. Hairy cell leukemia Leukemic reticuloendotheliosis
Originally B cells w/ hairlike projections
(+) TRAP: Tartrate-resistant acid phosphatase
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Terminal DNA polymerase immunoperoxidase
deoxyribonucleotidyl Marker for immature lymphocytes
Transferase (TdT) (+) ALL
(-) AML
Periodic Acid-Schiff (PAS) Marker for glycogen, glycoproteins, mucoproteins and
HMW CHO
a. Normal: all blood cells are PAS (+) except erythroblast
b. Abnormal: erythroblasts are PAS (+) = M6
(+) L1 and L2 = blocklike positivity
(-) L3
(+) M6
Naphthol AS-D Specific esterase
Chloroacetate esterase Marker for mature and immature neutrophils and mast
cells
(+) AML
(-) AMoL [M5]
(-) ALL
Lasts for months
α-Naphthyl Acetate Nonspecific esterase
esterase Marker for monocytes, megakaryocytes and plasma
cells
(+) AMoL [M5] = inhibited by fluoride
(+) AMegL [M7]
(-) AML
α-Naphthyl Butyrate Nonspecific esterase
esterase Identifies monocytes, promonocytes and monoblasts
(+) AMoL [M5] = inhibited by fluoride
(-) AML
Acid phosphatase Present in all hematopoietic cells and found in
lysosomes
(+) Hairy cell leukemia = TRAP (+)
(+) T cell leukemia
(-) Non-T cell leukemia
Cannot be stored
Tartrate resistant acid Excellent marker for hairy cell leukemia
phosphatase (TRAP)
Leukocyte alkaline Neutrophil is the only leukocyte that contains this
phosphatase (LAP)/ activity
Neutrophil ALP (NAP) Found in 3’ granules (Metamyelocytes)
Leukomoid reaction, MMM, PV, 3rd trimester of
pregnancy
CML, CGL, PNH
Should be done on fresh specimen
♫ Kaplow count:
= Count 100 neutrophils
= Grade 0 to 4+
NV = 30-185
LAP Score:
0 = No stain
1+ = Faint stain
2+ = Pale stain
3+ = Strong stain
4+ = Deep (Very intense) stain
Toluidine blue Binds w/ acid mucopolysaccharides in blood cells
Strongly metachromatic
Useful for recognition of mast cells and tissue basophils
(metachromatic granules)
CGL: Chronic granulocytic leukemia
Cooper & Cruickshank Stain for basophils
Reagent: Toluidine blue
Nitroblue tetrazolium test Test for CGD
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(Original) NBT: Colorless to pale yellow ---(Toxic O2 molecules)--->
(+) Blue formazan
Test:
♫ Heparinized blood Centrifuge Buffy coat (WBC) +
NBT (+) Formazan
NV = ≤10% formazan (+)
CGD = 0 to negligible
Infection = 70%
Modified NBT w/ stimulating agent
Test:
♫ Buffy coat (WBC) + Bacterial suspension ---(NBT)--->
(+) Formazan
NV = 80-100% formazan
CGD = <50% formazan
Feulgen reaction Specific reaction for DNA
Howell-Jolly bodies = Feulgen (+)
Prussian blue stain Stain for hemosiderin
(+) Sideroblast
(+) Siderocytes
Supravital stain (RHH) RHH = NCB
Reticulum = New methylene blue
Heinz bodies = Crystal violet
Hemoglobin H = Brilliant cresyl blue
BCB Stain for automated cell counter
HEMOSTASIS
Primary hemostasis Involves blood vessels and platelets
Formation of platelet plug
Test: Bleeding time
Platelets Functions:
Adhesion
Activation
Release
Aggregation
Secondary Involves the coagulation factors
hemostasis Formation of stable fibrin clot
Test: Clotting time
Arteries Carry blood from the heart to the capillaries
Primary Hemostasis
Veins Return blood from the capillaries to the heart
Capillaries Injured vessel: vasoconstriction
= initiated by serotonin and thromboxane A2 derived from
platelets and endothelial cells
Maturation Stage Cytoplasmic Cytoplasmic Nuclear Thrombocyte
Granules Tags Features s Visible
Megakaryoblast (-) (+) Single nucleus (-)
Fine chromatin
(+) Nucleoli
Promegakaryocytes Few (+) 2 nucleus (-)
Megakaryocytes Numerous Usually (-) 2 or more (-)
nuclei
Metamegakaryocyt Aggregated (-) 4 or more (+)
es nuclei
Platelet structure 60% proteins
30% lipids
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8% carbohydrate
Various minerals, water, nucleotides
1. Peripheral zone = responsible for adhesion and aggregation
a. Glycocalyx = outer surface
b. Plasma membrane = consists of 30 or more glycoprotein
c. Submembranous area
2. Sol-gel zone = platelet shape & contractile elements
a. Microfilaments: actin & myosin (actomyosin/thrombostenin)
= responsible for clot retraction
b. Microtubules = consists of tubulin: maintain the platelet
shape
3. Organelle zone
= alpha & dense granules
= mitochondria, lysosomal granules
4. Membranous system
a. Dense tubular system = site of arachidonic acid metabolism
b. Open canalicular system (surface connecting system) =
release of granules
Platelet Adhesion Platelet adherence to exposed subendothelial surface (collagen)
Occurs in the presence of von Willebrand factor
In vivo: collagen
In vitro: glass
Bernard-Soulier (-) gpIb = receptor for vWF
syndrome
(Giant platelet
syndrome)
Von Willebrand (-) vWF = for platelet adhesion
disease
Platelet Activation Morphologic and functional changes in platelets
Agonists: substance that initiate activation
Arachidonic acid ---(Cyclooxygenase)---> Thromboxane A2
TxA2 Vasoconstrictor
Stimulate platelet secretion
Aspirin Inhibits COX
bleeding time
Platelet Secretion Release of granules
a. Alpha granules
= Platelet factor
= Platelet derived growth factor
= Fibrinogen
= Factor V
= vWF
= β-thromboglobulin
= Thrombospondin
= Fibronectin
= Albumin
b. Dense granules (CAPAS)
= Calcium
= ADP
= Pyrophosphate
= ATP
= Serotonin
Release disorders Storage pool defects:
a. Alpha-granule deficiency
♫ Gray platelet syndrome
♫ Quebec platelet disorder = (-) Factor V binding protein
(multimerin)
b. Dense granule deficiencies
♫ Hermansky-Pudlak
♫ Chediak-Higashi
♫ Wiskott-Aldrich syndrome (α & dense granule deficiency)
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Important Substances Secreted by Platelets & Their Role in Hemostasis
Promote HMWK (α)
coagulation Fibrinogen (α)
Factor V (α)
Factor VIII:vWF (α)
Promote ADP (d)
aggregation Calcium (d)
Platelet factor 4 (α)
Thrombospondin (α)
Promote Serotonin (d)
vasoconstriction Thromboxane A2 precursors (mb.PL)
Promote vascular Platelet-derived growth factor (α) = promotes smooth muscle
repair growth
β-thromboglobulin (α) = chemotactic for fibroblasts
Other systems Plasminogen (α)
affected α2-antiplasmin (α)
C1 esterase inhibitor (α)
Platelet Platelet attachment to each other
aggregation Requires fibrinogen and Ca2+
Glanzmann’s (-) gpIIb/IIIa complex: receptor for fibrinogen
thrombasthenia
Petechiae Pinpoint hemorrhagic spots
Purpura Hemorrhage of blood into small areas of skin
Ecchymosis Blood escapes into large areas of skin
Epistaxis Nosebleed
Hemarthrosis Leakage of blood into joint cavities
Hematemesis Vomiting of blood
Hematoma Swelling or tumor in the tissues or a body cavity that contains
clotted blood
Hematuria RBC in urine
Hemoglobinuria Hgb in urine
Melena Stool containing dark red or black blood
Menorrhagia Excessive menstrual bleeding
Vascular Disorders
Hereditary Most common inherited vascular disorder
hemorrhagic Blood vessels are thin & lack smooth muscle
telangiectasia
(Oslwer-Weber-
Rendu disease)
Congenital Tumor composed of blood vessels
hemangiomata
(Kasabach-Merritt
syndrome)
Ehler-Danlos vascular fragility
syndrome
Marfan’s syndrome
Pseudoxanthoma Elastic fibers are calcified & structurally abnormal
elasticum
Senile purpura Degradation of collagen & elastin
Scurvy (-) Vitamin C = for collagen synthesis
Defective synthesis of collagen
Henoch-Schonlein Immunologic damage to endothelial cells
purpura
Quantitative Platelet Disorders
Thrombocytopenia Platelet production of BM = aplastic anemia
Survival time = platelet destruction (DIC, ITP)
Platelet sequestration by the spleen = splenomegaly
Dilution of platelet count = Thrombocytopenia α # of units
transfused
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Units transfused = Thrombocytopenia
Multiple transfusion: stored blood contains nonviable platelets
Thrombocytosis Reactive = moderate increase, asymptomatic (after
hemorrhage, splenectomy)
Autonomous = marked increase, associated w/
thrombotic/hemorrhagic complications (Ex. ET: platelet function
is abnormal)
Secondary Hemostasis
Coagulation factors All are produced in the liver except Factor VIII
In liver disease, all coagulation factors are except factor VIII
complex
Factor VIII complex:
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a. VIII: Coagulant (VIII:C)
b. vWF: produced by megakaryocytes and endothelial cells
Activated at cold temp. = VII & XI
Coagulation Factors
Numeral Preferred Name Synonyms
I Fibrinogen
II Prothrombin Prethrombin
III Tissue factor Tissue thromboplastin
IV Calcium
V Proaccelerin Labile factor
Accelerator globulin (aCg)
VII Proconvertin Stable factor
Serum prothrombin conversion
accelerator (SPCA)
VIII:C Antihemophilic factor Antihemophilic factor globulin
(AHG)
Antihemophilic factor A
Platelet cofactor 1
IX Plasma thromboplastin Christmas factor
component Antihemophilic factor B
Platelet cofactor 2
X Stuart-Prower factor Stuart factor
Prower factor
Autoprothrombin III
XI Plasma thromboplastin Antihemophilic factor C
component
XII Hageman factor Glass factor
Contact factor
XIII Fibrin stabilizing factor Laki-Lorand factor
Fibrinase
Plasma transglutaminase
Fibrinoligase
- Prekallikrein Fletcher factor
- High-molecular weight Fitzgerald factor
kininogen Contact activation cofactor
Williams factor
Flaujeac factor
Stage I: Generation Intrinsic: XIIXIIX—VIII (Cofactor)
of Thromboplastin Extrinsic: IIIVII
Common: X—V (Cofactor)
----> Common thromboplastin/Prothrombinase (Va-Xa-Ca2+-PL)
Stage II: Conversion II ---(Prothrombinase)---> Thrombin
of prothrombin to
thrombin
Stage III: I ---(Thrombin)---> Fibrin clot
Conversion of XIII---(Thrombin)---> XIIIa
fibrinogen to fibrin Fibrin clot ---(XIIIa)---> Stable fibrin clot
clot
Fibrinogen Most concentrated
Calcium Involved in all stages of coagulation except contact phase
Contact group XII, XI, PK, HMWK
Ca2+ independent
Vit. K independent
Involved in the contact phase
XII ---(Collagen)---> XIIa (small amount)
PK ---(XIIa)--------> Kallikrein
XII ---(Kallikrein+HMWK)---> XIIa (large amount)
XI ---(XIIa)---------> XIa
Fibrinogen group I, V, VIII, XIII
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Ca2+ dependent
Vit. K independent
Completely consumed during coagulation
(+) in plasma
(-) in serum
Prothrombin group II, VII, IX, X
Ca2+ and Vit. K dependent
First: VII IX X II: Last
Adsorbable factors: removed by adsorbing agents [BaSO4,
Al(OH)3]
(+) in plasma
(-) in serum
Diseases BT PT APTT Stypven TT Duckert
’s
Disease of 1’ N N N N N
hemostasis
Fibrinogen N* N
deficiency
Prothrombin N N N
deficiency
Parahemophilia N N N
Factor VII deficiency N N N N N
Hemophilia A N N N N N
von Willebrand N N N N
disease
Hemophilia B N N N N N
Factor X deficiency N N N
Hemophilia C N N N N N
Factor XII deficiency N N N N N
Factor XIII N N N N N Abn
deficiency
DIC Abn
*BT may be prolonged in afibrinogenemia
Adsorbed
Fresh Plasma Aged Plasma Fresh Serum Aged Serum
Plasma
I + + + - -
II + + - + (<20%) -
V + - + - -
VII + + - + +
VIII + - + - -
IX + + - + +
X + + - + +
XI + + + + +
XII + + + + +
XIII + + + - -
Prothrombin:
80% is consumed during coagulation
<20% residual prothrombin
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HEMATOLOGY PROCEDURES
Brightfield Examine blood films
microscopy
Oil immersion Erythrocyte morphology & leukocyte differential
microscopy
Phase-contrast For manual platelet counts
microscopy
Fluorescence ANA and T/B cell studies
microscopy
Electron microscopy Observation of fine ultrastructures of cells (100,000x
magnification)
Basic component of Diopter rings: adjust for focusing differences between eyes
Standard light Rubber eyeguard: adjust for comfort
microscope Eyepiece tube clamp screw: loosen to rotate head
Reverse facing nosepiece: for ease in specimen manipulation
Revolving nosepiece: use to rotate objectives
Objectives: lenses w/c form primary image of specimen
Field diaphragm: aperture diaphragm w/c restricts area of
illumination
Field diaphragm control ring: adjust size opening of field
diaphragm
Coarse focus knob: brings slide into view
Fine focus knob: sharpens image
Lamp socket: holds light source
Interpupillary distance scale: indicates distance between eyes
Eyepiece: magnify image formed by objective lens
Stage: holds specimen
Slide holder: holds slide in place
Condenser control ring: adjusts size opening of condenser
Condenser: aperture diaphragm that controls light
Condenser centering screws: center the field of view
Condenser focus know: focuses light onto slide
X/Y travel knobs: moves slides on stage
Brightness control dial: turns microscope on/off, adjusts light
intensity
Hemoglobin Determination
Hemoglobin AM, PM
Strenuous muscular activity
Altitude = Hgb
Lying down
Acid hematin Rgt: 0.1N HCl
Comparing the brownish yellow color of solution to standard
comparator block
Alkali hematin Rgt: 0.1N NaOH
Not for newborns (HbF: alkali resistant)
Gasometric (Van 1g Hgb = 1.34mL O2
Slyke)
Chemical 1g Hgb = 3.47mg Fe2+
(Kennedy’s,
Wong’s)
SG method CuSO4 method (See BB notes)
Cyanmethemoglobi Manual and automated
n/ Dilution = 0.02mL blood: 5mL rgt (1:251)
Hemiglobincyanide Reagents:
method Drabkin’s reagent (Brown container)
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a. Potassium ferricyanide = ferrous ferric
b. Potassium cyanide = Hi HiCN
c. Nonionic detergent = lysis of red cells, decreases turbidity
d. Sodium bicarbonate (Orig. Drabkin’s) = result is read after
15mins
e. Dihydrogen potassium phosphate (Mod. Drabkin’s) = result is
read after 3 mins
*Color intensity is measured at 540nm
*All forms of Hgb are measured except SulfHb
*Overanticoagulation does not affect result
♫ Turbidity = False
a. High WBC count: to correct, centrifuge read supernatant
b. HbS & HbC: to correct, dilute 1:1 w/ H2O result x 2
c. Lipemic blood: prepare patient’s blank (pt. plasma + HiCN rgt)
Rule of three 3 x RBC = Hgb
3 x Hgb = Hct
Apply only to normocytic, normochromic red cells
Hematocrit Determination
Macromethods Large volume of blood
1. Wintrobe & Landsberg = Double oxalate
2. Van Allen = Sodium oxalate
3. Haden = Sodium oxalate
4. Sanford-Magath = Sodium oxalate
5. Bray = Heparin
Centrifuge: 2000-2300g for 30mins
Layers (Spun Hct):
1st: Fatty layer = barely visible unless the patient is lipemic
2nd: Plasma
3rd: Buffy coat (1mm = 10,000 WBCs/mm3)
Bottom: Packed cells
Wintrobe tube Length = 11.5cm
Bore = 3.0mm
Calibration = 0-100
a. Left: 0-100 (ESR)
b. Right: 100-0 (Hct)
Micromethod Capillary tube:
(Adam) Length = 7.0-7.5cm (70-75mm)
Bore = 1mm
Anticoagulant: Red (Heparin)
No anticoagulant: Blue
Centrifuge: 10,000-15,000g for 5mins
Trapped plasma: plasma that remains in RBC portion after
spinning
= in poikilocytosis
♫ Advantages:
a. Better packing of cells
b. Less blood
c. Less time consumed
♫ Layers:
Top: Plasma
2nd: Platelets
3rd: Leukocytes
4th: Retics & nRBCs
5th: Mature RBCs
Bottom: Clayseal (4-6mm)
Automated Hct = only computed
methods Hct = MCV x RBC count
RBC Count
RBCs AM, PM
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RBC diluting fluids Isotonic solutions
1.) NSS
2.) 3.8% Sodium citrate
3.) Dacies or formol citrate
4.) Hayem’s
5.) Toisson’s
6.) Bethell’s
7.) Gower’s
Dilution (RBC pipette) = 0.5:100 (Blood: Diluent) = 1:200
RBC count RBC/mm3 = # RBC x AF x DCF x DF = # RBC x 5 x 10 x 200 = #
RBC x 10,000
WBC Count
WBCs AM, PM
WBC Diluting fluids Hypotonic solutions: lyse non-nucleated RBCs
1.) 1-3% acetic acid
2.) 1% HCl
3.) Turk’s diluting fluid: Gentian violet + glacial acetic acid (solid
at 17’C) + H2O
Mix = 3 mins (To allow lysis of RBCs)
Dilution (WBC pipette) = 0.5:10 (Blood: Diluent) = 1:20
Leukocytosis = Use RBC pipette (1:100 or 1:200)
WBC count WBC/mm3 = # WBC x AF x DCF x DF
Counting Chamber
Fuch’s Rosenthal 2 counting areas
Each CA w/ 16 1mm2 squares
Depth = 0.2mm
Depth factor = 5
Volume = Area x Depth x # CA = 16mm2 x 0.2mm x 2 = 6.4mm3
Volume/counting chamber = 3.2mm3
Speir’s Levy 4 counting areas
Each CA w/ 10 1mm2 squares
Depth = 0.2mm
Depth factor = 5
Volume = Area x Depth x # CA = 10mm2 x 0.2mm x 4 = 8mm3
Volume/counting chamber = 2mm3
Improved Neubauer 2 primary squares
Each 1’ square w/ 9 1mm2 2’ squares
Depth = 0.1mm
Depth factor = 10
Volume = Area x Depth x # CA = 9mm2 x 0.1mm x 2 = 1.8mm3
Volume/counting chamber = 0.9mm3
RBC count Center square:
w/ 25 3’ square
Each 3’ square w/ 16 small squares
25 x 16 = 400
5 (counted) x 16 = 80 small squares
WBC count 4 corners:
Each 2’ square w/ 16 3’ squares
4 x 16 = 64 3’ squares
Nucleated RBCs Not lysed by WBC diluents
Falsely counted as WBCs
NV:
Adult = ≥5 nRBC/100 WBC differential
Newborn = ≥10 nRBC/100 WBC differential
Formula for WBC Corrected WBC = uncorrected WBCs x 100
correction 100 + NRBCs
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Anemic patients Thicker smear:
- larger blood drop
- fast spread
- increase angle
Neutrophils Relative = 47-77%
Absolute = 1.8-7.8 x 109/L
Lymphocytes Relative = 20-40%
Absolute = 1.0-4.8 x 109/L
Monocytes Relative = 2-10%
Absolute = 0.01-0.8 x 109/L
Eosinophils Relative = 0-6%
Absolute = 0-0.6 x 109/L
Basophils Relative = 0-1%
Absolute = 0-0.2 x 109/L
Neutrophilia Appendicitis
Myelogenous leukemia
Bacterial infections
Eosinophilia Allergies
Scarlet fever
Parasitic infections (T. spiralis)
Eosinophilic leukemia
Lymphocytosis Viral infections
Whooping cough
IM
Lymphocytic leukemia
Lymphoma
Monocytosis Brucellosis
Tuberculosis
Monocytic leukemia
SBE
Typhoid
Rickettsial infections
Collagen disease
Hodgkin’s disease
Gaucher’s disease
Shift to the left (+) immature granulocytic cells
Leukemia
Bacterial infections
Shift to the right Hypersegmented neutrophils (≥6 lobes)
Reticulocyte count NV:
Adult = 0.5-1.5% (Ave: 1.0%)
Newborn = 2-6%
% Retics [# Retics ÷ # RBC (1000)] x 100
Absolute ARC = (% Retics ÷ 100) x RBC count (1012/L) x 1,000
reticulocyte count NV = 25-75 x 109/L
Corrected CRC = % Retics x (Patient Hct ÷ Normal Hct [0.45L/L])
reticulocyte count NV = 1
Reticulocyte General indicator of the rate of erythrocyte production increase
production above normal in anemias
index/Shift Indicates BM response to anemia
correction RPI = CRC ÷ Maturation time of retics in the blood
NV = 1 (Hct: 45%)
Maturation time of 1.0 day = Hct: 45 ± 5%
retics in the blood 1.5 days = Hct: 35 ± 5%
2.0 days = Hct: 25 ± 5%
2.5 days = Hct: 15 ± 5%
RPI > 3 Adequate response of BM to anemia
- Chronic hemolysis
- Recent hemorrhage
- Response to therapy
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RPI < 2 Inadequate response of BM to anemia
- Aplastic anemia
- Ineffective erythropoiesis (megaloblastic anemia)
Miller disk % Retics = Retics (A) ÷ [RBC (B) x 9] x 100
Eosinophil count NV = 50-350 x 106/L
Eosinophilia Allergic reactions
Parasitic infections
Brucellosis
Leukemias
Eosinopenia Hyperadrenalism (Cushing’s disease)
Shock
Administration of ACTH
Eosinophil diluting Composition:
fluids a. Phloxine/eosin/neutral red iodide = stains eosinophils
b. Propylene glycol = lyses RBCs
c. Na2CO3 = lyses WBCs except eosinophils, intensifies staining
of granules
d. Heparin = prevents clumping
Diluting fluids:
1. Pilot’s = phloxine
2. Manner’s = phloxine
3. Randolph’s = phloxine
4. Hinkleman = eosin
5. Tannen’s = neutral red iodide
Thorn’s test Assess adrenocortical function
Sample 1: fasting specimen
Sample 2: 4 hrs after administration of ACTH (eo. count)
Normal: Eo. count: 1 > 2 (lower by 50%)
Abnormal: Eo. count: 1 = 2 (hypoadrenalism)
X-axis
- Horizontal/abscissa
- Size of cells
Y-axis
- Vertical/ordinate
- Number of cells
Page | 38
Ohm’s law V=IxR
Where:
V = voltage
I = current
R = resistance
Positive error Count: “BEA”
♫ Bubbles
♫ Extraneous electrical pulses
♫ Aperture plug
Negative error Count
♫ Improper setting of aperture error
Polychromasia % of RBCs that are polychromatophilic
grading Slight = 1%
1+ = 3%
2+ = 5%
3+ = 10%
4+ = >11%
Normocytic, 1. Defective formation of RBCs or the presence of tumor
Normochromic RBCs cells in BM:
*Aplastic anemia
*Leukemia
*Hodgkin’s disease
*Multiple myeloma
*Leukoerythroblastosis
*Metastatic cancer
*Anemia of renal & endocrine disease
*Anemia of inflammatory disease
2. Abnormal hemoglobin, increased destruction of RBCs
*Certain acquired hemolytic anemia
*PNH
*Sickle cell anemia
*HDN
*Anemia of chronic renal insufficiency
Hemolytic anemias 1. Intrinsic defects w/in RBC
a. Hereditary – membrane defects
**Spherocytosis
**Elliptocytosis
**Acanthocytosis
**Stomatocytosis
**Rh null disease
b. Hereditary – enzyme defects
**G6PD
**PK
c. Hereditary – hemoglobinopathies
**Sickle cell disease
**Hemoglobin C disease
d. Unstable hemoglobin disease
**Hemoglobin E disease
e. Hereditary – defective globin synthesis
**Thalassemia
f. Acquired
**PNH
2. Extracorpuscular causes: nonimmune acquired hemolytic
anemias
*Chemicals, toxins, venoms
*Physical trauma: disorders causing fragmentation (burns,
cardiac replacement valves, MAHA, HUS)
3. Intracorpuscular causes: immune hemolytic anemias
*Isoimmune antibodies: incompatible blood transfusion, HDN
*Autoimmune antibodies: warm/cold reacting, drug-induced
4. Miscellaneous
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*Anemia of liver disease
*Sulfhemoglobinemia
*Porphyrias
*Methemoglobinemias
Page | 40