Integrative

Question 1

Sites of hemopoiesis:

Answer 1

Fetus 0-2 m (yolk sac) 2-7 m (liver, spleen) 5-9 m (Bone marrow) Infant Bone marrow (all bones) Adult Bone marrow (axial skeleton and proximal end of long bones).

Question 2

What is the difference between plasma and serum ?

Answer 2

Plasma contain all coagulation proteins while the serum lack most of them mainly the fibrinogen loss in clot formation.

• Plasma obtain from blood collected in tube contain anticoagulant while serum collected from blood in plain tube.
• Plasma mainly use in investigations of coagulation disorders while serum mainly use in biochemical and hormonal investigations.

Question 3

شنو المسار مال الخلايا حتى تصير RBCs

Answer 3

Basophilic erythroblast
Orthochromatic erythroblast
Reticulocytes
Mature RBCs

Question 4

Important cells in the BM for this process are precursor cells which including:

Answer 4

Proerythoblast.

• Early normoblasts.
• Intermediate normoblasts.
• Late normoblasts.
• Reticulocytes.

The cell gradually loss their nucleus until formation of reticulocyte as last precursor cell without nucleus.

Question 5

Reticulocytes

Answer 5

non nucleated red cells with diffusely basophilic cytoplasm due to remaining ribosomal RNA, still able to synthesis the Hb, slightly larger than mature RBC, it remains in BM about 2 days then release to circulation and remains 1-2 days to complete their maturation in the spleen. Normal range in peripheral blood is 0.5-2.5 % from each 100 mature RBC.

Question 6

Normoblast (precursor of RBC) normally present in the BM and not present in peripheral blood and when appear called

Answer 6

Normoblast (precursor of RBC) normally present in the BM and not present in peripheral blood and when appear called nucleated RBC (NRBC).

Question 7

Control of erythropoiesis:

Answer 7

Functional feedback: achieved by Erythropoietin (Epo).

• Certain hormones, like growth hormone and androgen enhance erythropoiesis, while estrogen suppresses erythropoiesis.
• Nutritional factors like FA, B12, iron, B6, B2, vitamin C and E.

Question 8

Erythropoietin (Epo):

Answer 8

It is a glycoprotein produced mainly by the kidney in the adult, stimulates red cell progenitors and precursors cells for RBC formation from the BM. Secretion of Epo is triggered by reduced oxygen carriage of blood:

• Reduced Hb (anemia).
• Hypoxia (cardiac and lung disease).
• Damage to renal circulation.

Epo of great clinical significant in many disorders using recombinant Epo like end stage renal disease and anemia of chronic disease.

Question 9

Retic count formula

Answer 9

HC / 45* Retic count
Correction for hyperchromasia
The result from above formula /2

Question 10

Bone marrow examination

Answer 10

Bone marrow aspirate: done from iliac crest or sternum, in which a specimen is aspirated using a wide bore needle from the active marrow, smeared, stained and then examined for any abnormalities.

2. Bone marrow biopsy: here a core of bone marrow tissue is taken, processed and stained as in histopathological specimens.

Question 11

Main indications of BM examination

Answer 11

Marrow infiltration with leukemia, lymphoma, secondary carcinomas and myelofibrosis.

2. Cytopenias of unexplained causes: neutropenia, thrombocytopenia, anemia.

Question 12

Hemoglobin (normal range for male
For female

Packed cell volume (PCV) also called Hematocrit (Male& female )
RBCs count

Answer 12

Hemoglobin (normal range for male 13.0– 17.0 g/dl, female 12.0-

15.0 g/dl).

Packed cell volume (PCV) also called Hematocrit (Male 40-50 %, Female 36-46 %).

• RBC count (Male 5.0 x 1012/L, Female 4.3 x 1012/L).

Question 13

MCV
MCH
MCHC
RDW
ESR

Answer 13

80-100 fl). (27-32 pg).

(32-36 g/dl). (12-15 %).
8 mm/hr

Question 14

Classification of anemia

Answer 14

BM defect , Retic count low or normal )

( Retic count increase )

Peripheral blood loss

Like:

1. Iron deficieny anemia
2. Megaloblastic anemia
3. Aplastic anemia
4. Anemia of chronic dis.
5. Anemia associated with BM infilteration.

Retic count increase )

Peripheral blood loss

1. Bleeding
2. Hemolysis (hemolytic anemia)

Question 15

Generally iron in the body present in main 3 pools are:

Answer 15

Functional pool: (65-70%)

• Hemoglobin: New RBC formation required 30 mg iron/day mainly derive from breakdown of old RBC. Each unit of blood (450ml) contains 200 mg iron.
• Myoglobin, mitochondria and iron containing enzymes.

(2) Storage pool: (20-25%) present in form of ferritin and hemosiderin that present in RES (BM, liver and spleen) and in the liver parenchymal cells.
(3) Transporting pool: (0.1%) plasma iron carried by iron transporting protein (Transferrin).

Question 16

Hepcidin

Answer 16

is a small peptide, formed by liver and consider the predominant negative regulator of iron absorption from small intestine (decrease in iron absorption) and iron release from macrophages (decrease in iron release from macrophage).

Question 17

Causes of iron deficiency:

Answer 17

1. Chronic blood loss: (at least 6-8 ml/day). Common cause in adult

and most likely from the gastrointestinal tract and in females

bleeding from genital tract is also quite common.

2. Increase in demand: prematurity and infancy (3-6 months), pregnancy, lactation, menstruation and adolescence period.
3. Nutritional: rarely to be the sole cause of ID but quite common cause of iron deficiency in developing and underdeveloped countries, especially if inadequate intake is coupled with increased demand.
4. Inadequate absorption: from many causes of malabsorption e.g.

Celiac disease.

Question 18

Clinical features:of IDA

Answer 18

Clinical features related to underlying pathology.

• General signs and symptoms of anemia.
• Mucosal changes in severe IDA as mouth soreness, painless glossitis, angular stomatitis and nails changes as brittle, ridged, and spooning (koilonychias) of nails.
• Pica (craving to eat unusual substances like clay and ice).
• In sever long standing IDA, patient may develop dysphagia (Plummer Vinson syndrome).
• Mental development disturbance and premature labor may associated.
• Plummer Vinson syndrome (Kelly Paterson syndrome) is a triad of dysphagia (pharyngeal web), glossitis and IDA, it has risk of CA, more in women, of unknown etiology.

Question 19

Anisocytosis

Poikilocytosis

Answer 19

Anisocytosis: change in RBC size as microcytic (decrease in MCV), macrocytic (increase in MCV).

• Poikilocytosis: change in RBC shape as sherocytes, target, tear, sickle, fragmented, oval, rod cells, etc

Question 20

Stages of iron deficiency anemia:

Answer 20

1. Depletion of iron stores: no iron in store (low serum ferritin) and no anemia yet.
2. Iron-deficient erythropoiesis: Low serum iron and high TIBC and still no significant anemia yet.
3. Iron deficiency anemia: Low Hb, MCV and MCH.

Question 21

Laboratory findings in IDA:

Answer 21

1. Hematological findings:

• Reduce in Hb (6-8 gm/dl) usually moderate degree of anemia.
• Reduce PCV, MCV, MCH, and MCHC.
• Retic count is low.
• WBC usually normal, and platelets counts often increase.
• Blood film: hypochromic microcytic.

LO5

• Decrease or absence in marrow iron store which can detect by Perl’s stain/Prussian blue stain which is diagnostic, but the BM examination is not an indication in suspected case of IDA.

2. Biochemical findings:

• Serum iron reduced.
• Total iron binding capacity increased.
• Transferrin saturation reduced <15%.
• Serum Ferritin reduced which reflects storage iron.

3. Investigations for suspected underlying causes

Question 22

Treatment of IDA

Answer 22

Treatment of primary cause.

• Oral iron (most effective) best with ferrous sulphate 200 mg (67 mg elementary iron).
• Dose 100-200mg elementary iron/day, for 3-6 months (to correct the storage state of iron).

Question 23

Response assessment to IDA

Parental iron

Answer 23

Response assessment by increase Hb (0.5-1gm/wk), retic count increase (peak at 10 days).

• Failure to response may related to wrong diagnosis, failure to take the drug, continuous hemorrhage, mixed anemias, another cause of anemia and malabsorption.

Parenteral iron: Indicated in sever intolerance of oral iron, require rapid restoring, persistent hemorrhage, malabsorption. Iron sorbitol (jectofer) IM, dextran (inferon) IV.

Question 24

Differential diagnosis of IDA

Answer 24

Differential diagnosis of hypochromic microcytic anemias include four main types of anemia are:

• Iron deficiency anemia.
• Anemia of chronic disease.
• Sideroblastic anemia, result from defect in protoporphyrin ring.
• Thalassemia, result from globin chain defect.

Question 25

Anemia of chronic disease | Causes

Answer 25

كلها بسبب السايتوكين تروح للبون مارو تقلل تخليق كريات الدم الحمر وتسوي أيضا upregulation of hepcidin

Question 26

Anemia of chronic disease | Clinical features

Answer 26

Mild to moderate anemia (rarely Hb < 9 gm/dl), start 1-3 months after the underlining disease and the severity related to illness severity. * Normochromic red cell in most cases or may be hypochromic in peripheral blood. * Low serum iron despite adequate iron stores (due to defect in iron mobilization from the storage sites by effect of hepcidin and other inflammatory mediators). * Low serum iron and low TIBC. * High serum ferritin, high C-reactive protein and high ESR. * High serum Hepcidin level (important acute phase protein with significant role in regulation of body iron).

Question 27

Megaloblastic anemia | Clinical

Answer 27

Anemia due to impaired DNA synthesis, result mainly from B12 and Folate deficiency. All haemopoietic cell lines (erythropiesis, granulopoiesis, megakaryopoiesis) are affected result in severe anemia and even pancytopenia. * The hallmark enlargement of BM erythroid precursors (megaloblast) give rise to abnormal large RBC in blood (macrocytes) in addition to giant granulocytic precursors in BM yielding hypersegmented neutrophils in peripheral blood. * It important to recognition of MBA because main causes can completely corrected with therapy and it is a serious disease that neurological and psychiatric abnormalities of B12 deficiency may be preventable and reversible with early stage of disease.

Question 28

Forms of B12

Answer 28

Forms of B12:Methylcobalamin, Adenosylcobalamin, main form in tissue, Cyanocobalamin, form use in investigations, Hydroxycobalamin, form use in treatment.

Question 29

Absorption of B12 in the ileum pass through some steps:

Answer 29

In stomach: B12 bind to R-factor which produce by saliva and gastric juice. * In duodenum: Digestion of this complex by pancreatic enzymes, then the B12 bind to Intrinsic factor (IF) which secrete from stomach parietal cells. * In terminal ileum: IF bind to specific receptor (Cubilin) and B12 appear in portal circulation after 6 hrs bind to transcobalamin-II (TC II).

Question 30

Folic acid

Answer 30

Human unable to synthesis FA so required intake, main source are vegetable and fruits, but most foods contain FA and it destroyed by cooking. * Absorption take place in upper half of small intestine mainly jejunum by saturation process. * It act as a co-enzyme in purine and pyrimidine synthesis.

Question 31

Biochemical basis of MBA:

Answer 31

MBA; is type of anemia characterized by impaired DNA synthesis. * DNA synthesis required polymerization of 4 deoxyribonucleoside triphosphates and FA deficiency impaired thymidylate of dUMP to dTMP. * B12 required to achieve the active form of folate inside the cells. * So deficiency of any vitamin will lead to impair in DNA synthesis. * Neurological manifestations occur only with B12 deficiency due to defect in methylation of myelin

Question 32

Causes of vitamin B12 deficiency:

Answer 32

(1) Malabsorption (main cause) like: o Gastric causes, as pernicious anemia. o Intestinal causes, as ileal resection. o Other causes like severe chronic pancreatitis. (2) Dietary deficiency: as in vegans, pregnancy, poverty, infancy (dietary cause unlikely related unless malabsorption association). (3) B12 abnormal metabolism: Acquired as nitrous oxide inhalation. Inborn error: as TC II and IF deficiency.

Question 33

Causes of FA deficiency:

Answer 33

(1) Inadequate dietary intake (common cause due to low storage state): old age, poverty, alcoholism, psychiatric disturbance. (2) Malabsorption like celiac disease. (3) Increase requirement or loss: - Physiological as pregnancy. - Pathological as hemolytic anemia. (4) Antifolate drugs as anti-convulsants, alcohol and DHFR inhibitors.

Question 34

Clinical features of MBA (of both B12 & FA deficiencies):

Answer 34

May be asymptomatic, usually insidious onset with signs and symptoms of anemia. * Mild jaundice (due to intramedullary destruction of red cell precursors). * Epithelial tissue changes as glossitis and angular stomatitis. * NTD (neural tube defect ) in FA deficiency and may occur with B12 deficiency of uncleare mechanisms. * Neurological manifestations only with B12 deficiency due to accumulation of SAH and reduce level of SAM in nervous tissue with defect in methylation of myelin. * Psychatric abnormality.

Question 35

Pernicious anemia

Answer 35

* It is MBA due to B12 deficiency, characterized by gastric atrophy, reduce or absent of intrinsic factor with achlorhydria. * It more in female, mostly a disease of the elderly, more in patients with autoimmune mediated disorders like autoimmune thyroid disease. * Not common in Iraq, common in north Europe. * Mostly it is autoimmune in nature with presence of serum antibodies like anti-IF Ab, anti-parietal cells Ab and anti-gasrtin receptor Ab.

Question 36

Laboratory findings of MBA:

Answer 36

Hematological findings: * Variable degree of anemia, usually severe anemia < 6 gm/dl. * MCV increased >100 fl, may be up to 135 fl. * Increase MCV, MCH, and normal MCHC. * Increase RDW. * Low retic count. * Leucocytes may be reduced, platelets may be moderately reduced (pancytopenia). * Blood film: oval macrocytes, hypersegmented neutrophils, leukoerythroblastic picture may found. * BM findings: Hypercellular marrow with megaloblastic changes in all cell lineages.

Question 37

Management of megaloblastic anemia

Answer 37

* Blood sample and BM examination done before any treatment. * General measures may require as platelets and RBC concentrate. * Treatment with specific vitamin if known, otherwise both vitamins should be given. * B12: lifelong B12 therapy using Hydroxocobalamin by injection. Six injections of 1mg IM for body restore then monthly injection for life. * Should never give folate on its own in cobalamin deficiency because although response will be seen, aggravation or induction of neurological complications may be induced. * FA: Folic acid given orally 5-15 mg / day. Duration usually 4 months, but depend on the underlying pathology may be for life in those with untreatable causes.

Question 38

Response to treatment: of megaloblastic anemia

Answer 38

* Initial correction of patient behavior and appetite within 1-2 days. * Retic count increase with peak level at 7 days may reach 40-50%. * Hb level increase 1 gm/dl /wk and corrected in 5-6 wks. * Peripheral neuropathy may partially improve but spinal cord damage is irreversible. * Follow up the patient with Hb and retic not by BM examination.

Question 39

BM failure

Answer 39

BM failure may result from: * Marrow infiltration or replacement by abnormal or malignant cells. * Hypoplasia/aplasia (inherited or acquired) either single line or all marrow lineage. Inherited type: Pancytopenia like Fanconi anemia. Single line: Anemia; Diamond Blackfan anemia. Neutropenia: Kostman’s syndrome. Thrombocytopenia of congenital type. Acquired type: Pancytopenia: Acquired aplastic anemia. Single line: Anemia; acquired pure red cell aplasia. Neutropenia: induce by drugs and viral infection. TCP: induce by drugs and viral infection.

Question 40

Pancytopenia

Answer 40

Definition: reduction in all cell line in peripheral blood (anemia, neutropenia, thrombocytopenia). Etiology of pancytopenia Central (BM) causes: * Aplastic anemia (congenital or acquired). * Some cases of acute and chronic leukemias. * Infiltration with abnormal or malignant cells. * Megaloblastic anemia (MBA). * Paroxysmal nocturnal hemoglobinurea (PNH). Increase peripheral destruction: Hypersplenism, SLE and DIC.

Question 41

Etiology of pancytopenia Central (BM) causes:

Answer 41

* Aplastic anemia (congenital or acquired). * Some cases of acute and chronic leukemias. * Infiltration with abnormal or malignant cells. * Megaloblastic anemia (MBA). * Paroxysmal nocturnal hemoglobinurea (PNH).

Question 42

Hypoplasia/aplasia Inherited type:

Answer 42

Pancytopenia like Fanconi anemia. Single line: Anemia; Diamond Blackfan anemia. Neutropenia: Kostman’s syndrome. Thrombocytopenia of congenital type.

Question 43

Hypoplasia/aplasia Acquired type:

Answer 43

Pancytopenia: Acquired aplastic anemia. Single line: Anemia; acquired pure red cell aplasia. Neutropenia: induce by drugs and viral infection. TCP: induce by drugs and viral infection.

Question 44

Aplastic anemia Definition

Answer 44

Pancytopenia in the peripheral blood due to aplasia or hypocellular marrow in which normal haemopoietic elements are replaced by fat cells. Abnormal cells are not present in the peripheral blood or bone marrow.

Question 45

Causes of AA: aplastic anemia

Answer 45

Inherited AA like Fanconi anemia. Acquired AA: 1. Idiopathic in 50 -75% of cases, most common type and suggested to be autoimmune T-cells mediated immune disorder. 2. Ionizing irradiation; Chemicals. 4. Drugs as: cytotoxic drugs, chloramphenicol, sulpha and gold. 5. Infective agents as hepatitis viruses, HIV, EBV, and other viruses.

Question 46

Clinical manifestations: of AA

Answer 46

* Any age but peak at 30 yrs. * Insidious or acute presentation. * Bleeding tendency. * Features of anemia. * Infections. * No jaundice except post-hepatitis cases. * No organomegaly.

Question 47

Laboratory Findings: of AA

Answer 47

* Pancytopenia (anemia, neutropenia, TCP). * Blood film: normochromic red cell and usually macrocytic. * Reduced retic count. * BMA: hypocellular, no abnormal cells. BMA may be dry (diagnosis cannot made with BMA alone). * BMB (required for diagnosis): hypocellular. * Cytogenetic analysis for congenital types.

Question 48

Hemoglobin H disease (Hb-H)

Answer 48

Common in South East Asia, less so in Mediterranean countries and sporadic in Iraq. The only phenotype of alpha thalassemia of clinical significance. Clinically: variable degrees of anemia, splenomegaly and jaundice. Unusual to see severe thalassaemic skeletal changes or growth retardation, usually survive to adult life. Anemia aggravated by infections and oxidant drugs.

Question 49

Laboratory findings: of alpha thal

Answer 49

Hb is usually 7-10 gm/dl, MCV and MCH reduced. * Reticulocytosis. * Blood film shows hypochromic microcytic cells, some target cells. * On modification of the reticulocyte stain; characteristic Hb-H inclusions will be seen in RBC (Golf ball appearance). * Hb electrophoresis showing Hb-H and Hb-A.