Hematology Final

Question 1

According to OSHA standards, when must hands be washed?

Answer 1

Hands must be washed before and after patient contact, after distributing specimens, handling body fluids, when visibly contaminated, after removing gloves/PPE, before leaving the clinical work area/lab, and, of course, after using the restroom.

Question 2

What are Standard Precautions?

Answer 2

Standard precautions require that when working with blood and specimens they are all assumed to be infectious and should be handled in that way via protective measures.

Question 3

Reticulocyte Production Index

Answer 3

• greater than 3 seen as adequate bone marrow response and less than 2 as inadequate bone marrow response

Question 4

3 phases of hematopoiesis

Answer 4

1. Mesoblastic phase (yolk sac)
2. Hepatic phase
3. Medullary (myeloid) phase

Question 5

Organ functions:

• Bone marrow
• Liver
• Spleen
• Lymph nodes
• Thymus gland

Answer 5

• Bone marrow - red marrow = makes cells (RBC, WBC, platelets). White marrow = sinus = “waiting room”
• Liver = major site of production during hepatic phase; back-up site when BM is shut down. Macrophages remove debris
• Spleen = filters circulating blood
• Lymph nodes = lymphocyte production, immunoglobulin processing, and filter lymph fluid
• Thymus gland = T lymphocyte development

Question 6

Cytokines

Answer 6

• play a major role in differentiating stem cells

- erythropoiesis, leukopoiesis, megakaryopoiesis

Question 7

Normoblastic Maturation

Answer 7

1. Pronormoblast
2. Basophilic normoblast
3. Polychromatic normoblast
4. Orthochromic normoblast
5. Reticulocyte
6. Erythrocyte

Question 8

Hypoxia and EPO

Answer 8

Hypoxia = the lack of oxygen in the blood stimulates erythropoeisis by signaling the release of erythropoietin from the kidney

EPO = erythropoietin decreases release time from bone marrow by stimulating the differentiation of stem cells into RBS. Also inhibits apoptosis.

Question 9

Extravascular vs. Intravascular Hemolysis

Answer 9

Extravascular = destruction of erythrocytes outside of vessels typically in the spleen = 95%

Intravascular = normally only 5% of destruction may occur in vessels.

Question 10

Synthesis of Hemoglobin

Answer 10

1. Heme + Globin pairs
2. alpha + non alpha make dimer
3. 2 dimers make tetramer
   = hemoglobin

Question 11

What chains make the following hemoglobin:

• A1
• A2
• F

Answer 11

A1 = 2 alpha + 2 beta
A2 = 2 alpha + 2 delta
F = 2 alpha + 2 gamma

Question 12

Oxygen Dissociation curve: Left Shift

Answer 12

• reduced p50 = higher oxygen affinity
• higher pH
• decrease in temperature, 2,3 – bisphosphoglycerate (BPG), or partial pressure of carbon dioxide (PCO2)

Question 13

Iron absorption molecules:

• Hepcidin­
• Ferritin
• Ferroporin
• Transferrin
• Hemosiderin

Answer 13

1. Hepcidin­ - regulates iron absorption by inhibiting release of iron from hepatic stores
2. Ferritin – major storage from of iron while in the enterocyte cytoplasm.
3. Ferroporin - transports iron from enterocyte cytoplasm to plasma.
4. Transferrin – transport protein to move iron (Fe 2+) from plasma to a hematopoietic cell in the bone marrow.
5. Hemosiderin­ - storage form of iron in macrophages (water-insoluble)

Question 14

“rule of three”

Answer 14

Hct = ( Hgb * 3 ) +/-­ 3

Question 15

Embden-Meyerhof Pathway

Answer 15

Hexose monophosphate pathway (shunt) = produces NADPH and reduced glutathione to protect red blood cells from oxidative stress by using G6PD.

Methemoglobin Reductase pathway = maintains heme iron in ferrous state (Iron 2+) by using NADPH and the enzyme methemoglobin reductase to reduce methemoglobin to hemoglobin.

Rapaport-­Luebering pathway = produces 2,3 ­DPG which regulates oxygen delivery to tissues.

Question 16

RBC life span

Answer 16

120 days

Question 17

Granules found in Neutrophils, Eosinophils, and Basophils

Answer 17

Neutrophils phagocytize to kill invading organisms.Contain secondary, tertiary, and secretory granules

Eosinophils are associated with allergic reactions, parasitic/helminth infections, and chronic inflammation. (cytokines, chemokines, growth factors, cationic proteins.)

Basophils are associated with the mediation of inflammatory responses and hypersensitivity of allergic responses. (histamine, interleukins, growth factors.)

Question 18

neutrophils vs. lymphocytes vs. monocytes.

Answer 18

Neutrophils are a part of the innate immune system, meaning they are non­specific.They are well known for their ability to phagocytize in order to destroy pathogens.

Monocytes become macrophages and present antigens to T and B lymphocytes helping initiate the adaptive immune response. They also help by phagocytizing microorganisms that are coated with antibodies. And are also responsible for cleaning up dead cells, debris, and old red blood cells.

Lymphocytes are important in the adaptive immune response because they include B cells (humoral immunity) that produce antibodies, T cells (cellular immunity), and NK cells. Their main function is regulation of the immune response.

Question 19

Granulocyte maturation

Answer 19

1. Myeloblast
2. Promyelocyte
3. Myelocyte
4. Metamyelocyte
5. Band Neutrophil
6. Segmented Neutrophil

Question 20

Four examples of unacceptable blood cell artifacts that occur in smears from EDTA tubes

Answer 20

1. echinocytic red blood cells
2. spherocytes
3. necrobiotic leukocytes
4. vacuolated neutrophils

Question 21

Calculate WBC count

Answer 21

of WBC counted * 1/(volume*# squares counted) * dilution = WBC count

Question 22

Calculate MCH, MCV, and MCHC

Answer 22

MCH (pg) = Hgb / RBC *10
MCV (fL) = Hct / RBC *10
MCHC (%)=Hgb / Hct * 100

Question 23

Pernicious Anemia

Answer 23

• autoimmune disease where antibodies are made against intrinsic factors and/or parietal cells = no intrinsic factor production

Question 24

absorption, transport, and storage of vitamin B12

Answer 24

Vitamin B12 is obtained from our diet. In the stomach, pepsin and HCl release vitamin B12 from the food protein. It is picked up by R ­binder and transported to the small intestine. Trypsin releases vitamin B12 so that it can be picked up by intrinsic factors. The intrinsic factor binds with enterocytes to absorb vitamin B12 into the blood. It is picked up by transcobalamin that brings it to cells/tissue/bone marrow that need Vitamin B12 or to the liver for storage.

Question 25

Aplastic Anemia

Answer 25

- loss/replacement bone marrow elements | - decreased reticulocytes, pancytopenia, normochromic and normocytic anemia

Question 26

Intrinsic and extrinsic hemolytic anemia

Answer 26

Intrinsic and extrinsic hemolytic anemia is a shortened life span of red blood cells Intrinsic hemolytic anemia is caused by an issue within the red blood cell. These causes are typically inherited. Extrinsic hemolytic anemia is due to something outside of the red blood cell such as antibodies or drugs. It is typically acquired.

Question 27

immune hemolysis mediated by immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies

Answer 27

- cause extrinsic hemolytic anemia. - IgM are large antibodies that activate complement in the plasma. The last complement added in the cascade causes hemolysis. Typically, IgM causes intravascular hemolysis. - IgG is smaller than IgM. It can tag red blood cells so that they are removed by the spleen. IgG’s size allows it to cross the placenta and harm the baby. Typically causes extravascular hemolysis.

Question 28

three mechanisms of drug ­induced hemolytic anemia

Answer 28

1. Autoimmune – Drug causes the PRODUCTION OF ANTIBODIES antibodies that attach to the red blood cell so they are destroyed by the spleen. 2. Drug Adsorption – Drug BINDS TO RBC and then elicits an immune response to be hemolyzed in the spleen. 3. Immune complex – An antibody and drug form a COMPLEX that in turn bind to the red blood cell and start a complement cascade. Activated complement is typically associated with intravascular hemolysis.

Question 29

amino acid substitutions in Hgb S and C

Answer 29

Hgb S- substitution of valine for glutamic acid. | Hgb C- substitution of lysine for glutamic acid.

Question 30

Which hemoglobins co ­ migrate with Hgb S on alkaline electrophoresis?

Answer 30

- Hemoglobins D and G co­migrate with Hgb S on an alkaline electrophoresis (cellulose acetate). - However, Hgb S migrates by itself on an acid electrophoresis (citrate gel).

Question 31

Thalassemia vs. Hemoglobinopathy

Answer 31

``` Thalassemias = quantitative disorder Hemoglobinopathies = qualitative disorder ```

Question 32

Four basic clinical syndromes of alpha ­thalassemia

Answer 32

Silent Carrier – deletion of one alpha gene­. This person appears normal. Alpha­ thalassemia trait – deletion of two alpha genes on one chromosome or one from each. 50% alpha chain production leads to low Hgb A2. Hemogliobin H disease – deletion of three alpha genes means only a 25% production of alpha chains. This leads to the formation of many Hgb H (4 beta chains) Hydrops Fetalis – deletion of all four alpha genes. A fetus with this deficiency will not survive.

Question 33

Beta-­thalassemia trait and homozygous beta thalassemia.

Answer 33

Trait - elevated A2 hemoglobin - basophilic stippling - Microcytic, hypochromic, and mild poikliocytosis Homozygous - Target cells, teardrop cells, elliptocytes, and numerous nRBC - Microcytic, hypochromic, with marked poikilocytosis

Question 34

WBS and other disorders: - Pelger ­Huet Anomaly - Alder ­Reilly Anomaly - May ­Hegglin Anomaly - Niemann ­Pick Disease - Tay Sach Disease - Gaucher’s Disease - Chronic Granulomatous Disease

Answer 34

1. Pelger ­Huet Anomaly- Neutrophil hyposegmentation 2. Alder ­Reilly Anomaly - Mucopolysaccharidosis associated with dark­ staining, coarse cytoplasmic granules in leukocytes (large purple granules). 3. May ­Hegglin Anomaly- Neutrophils contain blue­staining inclusions that resemble Dohle bodies; giant platelets 4. Niemann ­Pick Disease- Sphingomyelinase deficiency 5. Tay Sach Disease - Hexosaminidase A deficiency 6. Gaucher’s Disease - Beta glucocerebrosidase deficiency 7. Chronic Granulomatous Disease - Defect in respiratory burst

Question 35

Features of infectious mononucleosis

Answer 35

- caused by the Epstein ­Barr virus which causes the body to respond with an increase in lymphocytes (lymphocytosis) which leads to leukocytosis + reactive lymphs - symptoms:a fever, lymphadenopathy (swollen lymph nodes), and a sore throat.

Question 36

Describe the peripheral blood findings in chronic lymphocytic leukemia (CLL) and hairy cell leukemia.

Answer 36

CLL - lymphocytosis, mainly mature/normal - many smudge cells - decreased RBCs - decreased platelets - relative neutropenia Hairy cell leukemia - lymphocytosis, - characteristic “hairy cell” lymphocytes from shaggy cytoplasmic projections

Question 37

Lymphomas

Answer 37

- malignant neoplasms found in the lymphoreticular system - strongest risk factors: the immunocompromised or have an autoimmune disease; Viral and bacterial infections; chemicals and herbicides - most are a nodal disease

Question 38

Multiple Myeloma

Answer 38

- seen most commonly in elderly - symptoms include bone pain and destruction, pallor, fatigue, infections, kidney problems, and neuropathy - bone marrow: plasma cells, mott cells, flame cells,russel bodies, dutcher bodies - peripheral blood: plasma cells, rouleaux, teardrop cells

Question 39

Polycythemia Vera (PV)

Answer 39

- type of Myeloproliferative Neoplasm - Cell line: Erythroid - Occurs between 40-60 years of age. - Panmyelosis, absolute erythrocytosis - platelets: increased - basophilia - 95% JAK 2+ - increased LAP - More frequently in males. - Cardiovascular disease, splenomegaly(75%), hepatomegaly (40-50%). - Treatment with phlebotomy and myelosuppressive therapy. - Acute leukemia may develop in 5-10% patients

Question 40

Essential Thrombocythemia (ET)

Answer 40

- type of Myeloproliferative Neoplasm - Cell line: Megakarytocytic - Peak incidence 50-60 years of age - Extreme thrombocytosis, leukocytosis - platelets: Giant; bazaar - Eos and Basos - 50% JAK 2+ - Splenomegaly, Bleeding, thrombosis

Question 41

Primary Myelofibrosis (PMF)

Answer 41

- type of Myeloproliferative Neoplasm - Cell line: Fibroblast - Leukoerythroblasticanemia - platelets: giant, bizarre, hypogranular - Eos and Basos - 50% JAK 2+ - Anisocytosis, poikilocytosis, basophilic stippling - Extramedullary hematopoiesis

Question 42

Chronic Myelogenous Leukemia (CML)

Answer 42

- type of MPN - Cell line: Myeloid (neutrophils, eosinophils, basophils) - extreme leukocytosis - platelets increased - Eos and Basos - Philadelphia chromosome t(9,22) in 95% of patients (better prognosis) - disease of middle ages (46-58) - Extramedullary granulocytic proliferation in spleen and liver - Three phases: chronic, accelerated, and acute (blastic phase)

Question 43

Primary and Secondary polycythemia.

Answer 43

Primary polycythemia: - polycythemia vera (PV) - increase in all cell line precursors = panmyelosis - increased LAP - increased RBC mass - caused by leukemia Secondary polycythemia: - caused by high altitude, 2­3 DPG deficiency, high affinity hemoglobin, or tumors - only an increase in RBC precurors - normal RBC mass when the cause is identified - normal LAP

Question 44

Myelodysplasia

Answer 44

- the decrease of certain cells in a cell line (cytopenia) | - different morphological abnormalities include: dyserythropoiesis, dysmyelopoiesis, and dysmegakaryopoeisis.

Question 45

AML vs. ALL

Answer 45

AML - More common in adults and newborns < 1 year old - stain positive in SBB, MPO, and CAE ­- Prognosis related to genetic abnormalities - Clinical Features: Pallor, Bruising, Bleeding, Lymphnode enlargement rare, DIC - Laboratory Features: WBC count: 5­30 x 109/L, Myeloblasts present 90% of the time, CSF can have malignant cells, Hyperuricemia, Hyperphosphatemia, Hypocalcemia, Hypokalemia ALL - More common in children - stain positive in tDt and PAS - Prognosis related to age, tumor burden, immunophenotype, genetic abnormalities, organomegally - Clinical Features: Mucosal bleeding, Lymphadenopathy, Splenomegally, Hepatomegally, Bone pain - Laboratory Features: Half have leukocytosis and may not have circulating lymphoblasts, Malignant cells infiltrating the bone, meminges, testes and ovaries, Lymphoblasts in cerebral spinal fluid.

Question 46

Acute vs. Chronic Leukemia

Answer 46

Acute Leukemia - Greater than 20% blasts - Rapid proliferation of cells - Can quickly become fatal - Effects all ages - WBC count can be increased, normal, or decreased ``` Chronic Leukemia - Less than 20% blasts - ­Gradual proliferation (builds up) ­- More indolent -­ Effects adults more -­ WBC count very elevated ```

Question 47

WHO classification

Answer 47

- Acute myelogenous leukemia classification (world health organization) - uses cytogenetics, molecular characterization (morphology), and flow cytometry

Question 48

Brief description of each molecular methodology and give an example of a clinical application 1. Southern blot analysis 2. Polymerase chain reaction (PCR) 3. Reverse transcriptase polymerase chain reaction 4. In situ hybridization

Answer 48

1. Southern blot analysis- After gel electrophoresis separates the DNA fragments, the bands are transferred to a nitrocellulose filter with a probe which hybridize to target DNA. It is an important tool in the diagnosis and monitoring of lymphoproliferative disorders such and B­cell and T­cell lymphomas. Band = monoclonal, smear = polyclonal. 2. Polymerase chain reaction (PCR)Mimics in­vivo DNA replication and can generate millions of copies in a very short amount of time (hours) using a thermocycler. PCR aids in the detection of sickle cell because it amplifies the number of beta­globin genes in order to find the single nucleotide substitution. 3. Reverse transcriptase polymerase chain reaction - reverse transcriptase allows one to generate cDNA copies from mRNA; can be used to detect the chimeric mRNA that is transcribed from the Philadelphia chromosome. 4. In situ hybridization- Uses labeled nucleic acid probes that will hybridize to a target RNA or DNA sequence. It is useful in detecting polymorphisms and mutations. Ex: diagnosis of CML t(9;22) and APL t(15;17); and useful in monitoring the progress of a patient's disease or transplant

Question 49

thrombocytopenia vs. thrombocytosis

Answer 49

Thrombocytopenia: - decreased count in platelets typically less than 100 K/uL - due to decreased production or increased destruction or consumption. Thrombocytosis - increase in platelet count over 450 K/uL

Question 50

Describe the effect of aspirin on the release reaction of platelets

Answer 50

- Aspirin inactivates cyclooxygenase. Cyclooxygenase is important in the prostaglandin pathway. It makes arachidonic acid into prostaglandin endoperoxides which is then made into thromboxane A2 by thromboxane synthetase. Thromboxane A2 is required for platelet release and aggregation. Removing cyclooxygenase from this processes results in an irreversible inactivation of platelets - abnormal ADP and epinephrine

Question 51

Describe the defect in each of the following hereditary disorders: 1. Gray Platelet Syndrome 2. Bernard Soulier Syndrome 3. Glanzmann Thrombasthenia 4. von Willebrand Disease

Answer 51

1. Gray Platelet Syndrome: lack of alpha granules leaves the platelet with a gray appearance. 2. Bernard Soulier Syndrome: Lack of Glycoprotein, GP 1b, which is the site for adhesion. = abnormal ristocetin 3. Glanzmann Thrombasthenia: Abnormal Glycoprotein, PR IIb/IIIa, which is the site for aggregation. = Collagen abnormal 4. von Willebrand Disease: lack/abnormality of von Willebrand factor that results in decreased platelet adhesion to vessel wall. It is the most common inherited bleeding disorder. = abnormal ristocetin