Preface

iv

PART ONE

THE PRINCIPLES OF HEMATOLOGY

1

1

Safety and Quality in the Hematology Laboratory

1

An Overview of the Hematology Laboratory

1

The Study of Hematology

1

Functions of the Hematology Laboratory

1

Safety in the Hematology Laboratory

2

The Safety Officer

2

Occupational Safety and Health Administration Acts and Standards

2

Avoiding Transmission of Infectious Diseases

3

Immune Status: Screening and Vaccination

5

Safe Work Practices and Protective Techniques for Infection Control

6

Safety Manual, Policies, and Practices

6

Standard Precautions

6

Handwashing

6

Personal Protective Equipment

7

Decontamination of Work Surfaces, Equipment, and Spills

8

General Infection Control Safety Practices

9

OSHA Medical Waste Standards

11

Quality Assessment in the Hematology Laboratory

12

Regulations and Organizations Impacting Quality

12

Components of Quality Assessment

12

Nonanalytical Factors in Quality Assessment

12

Quality Control in the Hematology Laboratory

16

Terms Used in Clinical Quality Control

16

Functions of a Quality Control Program

17

Using Statistical Analysis of Results in Quality Assessment

18

Other Statistical Applications in the Hema Tology Laboratory

20

Chapter Highlights

20

Review Questions

21

Bibliography

23

2

Principles of Blood Collection

25

Quality in Phlebotomy

25

Quality Assessment

25

Patient Care Partnership

25

The Phlebotomist as Laboratory Ambassador

26

Patients with Special Considerations

26

Pediatric Patients

26

Adolescent Patients

26

Geriatric Patients

26

Blood Collection Supplies and Equipment

26

Anticoagulants

26

Adverse Effects of Additives

27

Safe Blood Collection

27

Evacuated Blood Collection Tubes

29

Anticoagulants and Additives in Evacuated Blood Tubes

31

Capillary Blood

31

Specimen Handling Requirements

32

Chapter Highlights

45

Review Questions

47

Reference

48

Bibliography

48

3

Molecular Genetics and Cellular Morphology

50

Cellular Infrastructure and Organization

50

Cellular Membranes

50

Cell Volume Homeostasis

52

Reactive and Neoplastic Growth Processes

53

Cytoplasmic Qrganelles and Metabolites

53

Cellular Inclusions and Metabolites

54

Nuclear Characteristics

54

Chromosomes

56

Activities of the Nucleus

58

The Foundations of Genetic Interactions

60

Genetic Alterations

61

Molecular Techniques in Hematology

63

Minimal Residual Disease

63

Hematopathology

67

Gene Rearrangement Studies

69

Chapter Highlights

69

Review Questions

70

Bibliography

72

4

Hematopoiesis

73

Hematopoiesis Defined

73

Origin of Blood Cells

73

Types of Human Stem Cells

73

Early Development of Blood Cells

73

Bone Marrow Sites and Function

75

Cellular Elements of Bone Marrow

76

Progenitor Blood Cells

76

Erythropoiesis

79

Granulopoiesis

79

Lymphopoiesis

79

Megakaryopoiesis

79

Other Cells Found in Bone Marrow

79

Interleukins

79

Hematopoietic Growth Factors

82

Examination of Maturing Blood Cells

83

General Cellular Characteristics

83

Nuclear Characteristics

83

Cytoplasmic Characteristics

85

Mature Blood Cells in Peripheral Blood

86

Chapter Highlights

86

Review Questions

87

Bibliography

87

PART TWO

ERYTHROCYTES

89

5

Erythrocyte Maturation, Physiology, and Lifecycle

89

Erythropoiesis

90

Erythropoietin

90

General Characteristics of Maturation and Development

91

Developmental Stages

92

Reticulocytes

94

Disorders Related to Erythrocyte Maturation and Production

97

Disorders of Erythropoietin

97

Red Cell Increases

98

Defective Nuclear Maturation

98

Characteristics and Biosynthesis of Hemoglobin

98

Genetic Inheritance of Hemoglobin

98

Chemical Composition and Configuration of Hemoglobin

98

The Role of 2,3-Diphosphoglycerate

99

Oxygen Dissociation and Alterations

99

Carbon Dioxide Transport

100

Biosynthesis of Hemoglobin

101

Disorders Related to Hemoglobin Biosynthesis

104

Disorders of Heme (Porphyrin) Synthesis

104

Disorders of Iron Metabolism

105

Disorders of Globulin Synthesis

108

Ontogeny of Hemoglobin

108

Variant Forms of Normal Hemoglobin

109

Abnormal Hemoglobin Molecules

110

Analysis of Hemoglobin

110

Membrane Characteristics and Metabolic Activities of Erythrocytes

111

Membrane Characteristics

112

Cytoplasmic Characteristics

113

Metabolic Activities

113

Catabolism of Erythrocytes

114

Measurement of Erythrocytes

116

Mean Corpuscular Volume

116

Mean Corpuscular Hemoglobin

117

Mean Corpuscular Hemoglobin Concentration

117

Chapter Highlights

118

Case Studies

119

Review Questions

121

Bibliography

124

6

Erythrocyte Morphology and Inclusions

126

Erythrocytes: Normal and Abnormal

126

Types of Variations in Erythrocyte Size

126

Kinds of Variations in Erythrocyte Shape

127

Alterations in Erythrocyte Color

134

Varieties of Erythrocyte Inclusions

135

Alterations in Erythrocyte Distribution

137

Parasitic Inclusions in Erythrocytes

137

Malaria

137

Other Parasitic Inclusions

141

Chapter Highlights

142

Case Study

142

Review Questions

143

Bibliography

144

7

Classification and Laboratory Assessment of Anemias

145

Causes of Anemia

145

Clinical Signs and Symptoms of Anemia

145

Classification of Anemias

145

Laboratory Assessment of Anemias

146

Quantitative Measurements of Anemia

147

Semiquanlitaiive Grading of Erythrocyte Morphology

147

Supplementary Assessment of Anemias

148

Chapter Highlights

148

Review Questions

148

Bibliography

149

8

Acute and Chronic Blood Loss Anemias

150

Acute Blood Loss Anemia

150

Etiology

150

Physiology

150

Laboratory Findings

150

Chronic Blood Loss Anemia

150

Etiology

150

Chapter Highlights

151

Case Studies

151

Review Questions

153

Bibliography

153

9

Aplastic and Related Anemias

154

Aplastic Anemia

154

Etiology

154

Pathophysiology

155

Clinical Features

158

Laboratory Findings

158

Treatment

158

Congenital Red Blood Cell-Related Disorders

159

Telomeres

159

Laboratory Findings in Bone Marrow Failure Syndromes

160

Pure Red Cell Aplasia

160

Diamond- Blackfan Anemia

160

Fanconi Anemia

161

Transient Erythroblastopenia of Childhood

162

Congenital Dyserythropaietic Anemia

163

Chapter Highlights

163

Case Studies

163

Review Questions

165

Bibliography

165

10

Iron Deficiency Anemia and Anemia of Chronic Inflammation

166

Scope of the Problem

166

Iron Deficiency Anemia

166

Early Diagnosis

166

Etiology

166

Epidemiology

167

Physiology

168

Pathophysioiogy

169

Clinical Signs and Symptoms

170

Laboratory Characteristics

170

Anemia of Inflammation or Anemia of Chronic Disorders

173

Etiology

173

Pathophysiology

173

Laboratory Characteristics

174

Treatment

175

Chapter Highlights

175

Case Studies

176

Review Questions

179

Bibliography

180

11

Megaloblastic Anemias

181

Megaloblastic Anemias

181

Etiology

181

Epidemiology

182

Physiology

182

Vitamin B₁₂ (Cobalamin) Transport

182

Vitamin B₁₂ (Cobalamin) and Folk Acid Deficiencies

183

Pathophysiology

184

Gastric Pathological Findings

184

Clinical Signs and Symptoms

186

Laboratory Findings

186

Treatment and Monitoring Therapy

188

Chapter Highlights

188

Case Study

190

Review Questions

191

Bibliography

191

12

Hemolytic Anemias

192

Hemolytic Anemias

192

Inherited Hemolytic Anemia

192

Acquired Hemolytic Anemia

197

Pathophysiology

200

Diagnostic Tests

201

Paroxysmal Nocturnal Hemoglobinuria

201

Etiology

201

Epidemiology

202

Pathophysiology

202

Clinical Signs and Symptoms

202

Laboratory Findings

203

Treatment

203

Paroxysmal Cold Hemoglobinuria

203

Chapter Highlights

203

Case Studies

204

Review Questions

207

Blbliography

208

13

Hemoglobinopathies and Thalassemias

210

Hemoglobin Defects

210

Demographics

210

Etiology

210

Sickle Cell Disease

211

Etiology

212

Epidemiology

212

Pathophysiology

212

Clinical Signs and Symptoms

213

General Signs and Symptoms

214

Laboratory Testing

214

Special Laboratory Testing

215

Management of Sickle Cell Disease

216

Sickle Cell Syndromes: Pathogenesis and New Approaches

218

Sickle β-Thalassemia

218

Sickle-α Disease

219

Sickle Cell Trait

219

Thalassemia

220

Demographics

220

Etiology

220

Pathophysiology

220

β-Thalassemia

220

α-Thalassemia

223

Other Hemoglobinopathies

224

Hemoglobin C Disease

224

Hemoglobin SC Disease

224

Hemoglobin D Disease

224

Hemoglobin E Disease

224

Hemoglobin H Disease

225

Methemogiobinemia

225

Unstable Hemoglobins

225

Hereditary Persistance of Fetal Hemoglobin

225

Chapter Highlights

226

Case Studies

227

Review Questions

232

Bibliography

233

PART THREE

LEUKOCYTES

235

14

Leukocytes: The Granulocytic and Monocytic Series

235

Introduction

235

The Granulocytic Series

235

Production of Neutrophils, Eosinophils, and Basophils

235

Sites of Developmentand Maturation

236

Development and Proliferation of Neutrophils, Eosinophils, and Basophils

236

Distribution of Neutrophils, Eosinophils, and Basophils

236

Normal Maturational Characteristics of Neutrophils, Eosinophils, and Basophils

237

Mature Forms

239

Granulation in Mature Forms

239

The Monocytic-Macrophage Series

240

Production and Development of monocytes and Macrophages

240

Morphological Characteristics

241

Reference Ranges of Granulocytes and Monocytes

241

Functional Properties of Granulocytes and Monocytes

242

General Characteristics

243

The Role of Macrophages

243

Acute Inflammatory Response

243

Sepsis

245

Steps in Phagocytosis

245

Specialized Functions of Granulocytes

247

Assessment Methods

248

Total Leukocyte Count

248

Differential Blood Smear Evaluation

248

Absolute Cell Counts 24s

Erythrocyte Sedimentation Rate

248

Assessment of Eosinophils and Basophils

249

Leukocyte Alkaline Phosphatase Test

249

Neutrophilk Function

249

Neutrophilic Hypersegmentation Index

249

Chaffer Highlights

249

Case Study

250

Review Questions

251

Bibliography

253

15

Nonmalignant Disorders of Granulocytes and Monocytes

254

Quantitative Disorders

254

Leukocytosis

254

Leukocytopenia

255

Morphological Abnormalities of Mature Granulocytes

256

Toxic Granulation

256

Döhle Bodies

256

Hypersegmentation

256

Pelger-Huet Anomaly

256

May-Hegglin Anomaly

257

Chediak-Higashi Syndrome

257

Alder-Reilly Inclusions

258

Ehrlichia

258

Abnormalities of Mature Granulocytes in Body Fluids

258

Qualitative Disorders

258

Defective Locomotion and Chemotaxis

258

Defects in Microbicida! Activity

259

Other Functional Anomalies of Neutrophils

259

Monocyte-Macrophage Disorders

259

Gaucher Disease

259

Niemann-Pick Disease

260

Chapter Highlights

260

Case Studies

260

Review Questions

264

Bibliography

265

16

Leukocytes: Lymphocytes and Plasma Cells

266

Anatomical Origin and Development of Lymphocytes

266

Sites Oflymphocytic Development

266

Lymphocyte Physiology

267

Normal Reference Values

267

Determining Absolute Lymphocyte Values

268

Morphological Characteristics of Normal Lymphocytes

268

Maturational Stages

269

Specific Lymphocyte Morphological Variations

272

Characteristics of Lymphocytes

273

Major Lymphocyte Categories and Functions

273

Monoclonal Antibodies

274

Major Lymphocyte Membrane Characteristics and Development

274

Functional Testing of Lymphocytes

277

Plasma Cell Development and Maturation

277

Plasma Cell Development

277

Maturational Morphology

277

Plasmacytoid Lymphocytes

277

Plasma Cell Disorders

278

Chapter Highlights

278

Review Questions

279

Bibliography

280

17

Leukocytes: Nonmalignant Lymphocytic Disorders

281

Characteristics of Lymphocytes

281

Lymphocytosis

281

Disorders Associated with Lymphocytosis

282

Infectious Mononucleosis

282

Cytomegalovirus Infection

286

Toxoplasmosis

287

Infectious Lymphocytosis

288

Bordetetla Pertussis (Haemophilus Pertussis) Infection

285

Lymphocytopenia

289

Immune Disorders Associated with Lymphocytopenia

289

Digeorge Syndrome

289

Acquired Immunodeficiency Syndrome(HIV/AIDS)

289

Systemic Lupus Erythemalosus

293

Chapter Highlights

294

Case Studies

294

Review Questions

297

Bibliography

297

18

Characteristics of Leukemias, Lymphomas, and Myelomas

298

Comparison of Leukemias, Lymphomas, and Myelomas

298

Forms of Leukemia

298

Classifications of Leukemias

299

French-American-British Classification

299

World Health Organization Classification

299

Prognosis and Treatment

300

Factors Related to the Occurrence of Leukemia

300

Genetic and Immunological Factors

300

Occupational Exposure

302

Environmental Exposure

302

Chemical and Drug Exposure

302

Genetic Abnormalities and Associations

302

Viral Agents

303

Secondary Causes of Leukemias

303

Demographic Distribution of Leukemia and Lymphomas

304

Ethnic Origin and Race

304

Gender

305

Chapter Highlights

305

Review Questions

306

Bibliography

306

19

Acute Leukemias

307

Introduction

307

Epidemiology of Acute Leukemias

307

Prognosis of Acute Leukemias

308

French-American-British and World Health Organization Categories

308

French-American-British (FAB) Classification

308

World Health Organization (WHO) Organization Gasification

308

General Characteristics of Acute Myeloid Leukemias

309

Genetic Differences

309

Micro-RNAs

310

Acute Myeloid Leukemia

310

FAB M0

311

Acute Myeloid Leukemia (FAB Ml)

311

Acute Myeloid Leukemia (FAB M2)

312

Acute Promyelocytic Leukemia (FAB M3)

312

Acute Myelomonocytic Leukemia (FAB M4)

313

Acute Monocytic Leukemia (FAB M5)

314

Erythrokukemk (FAB M6)

315

Selected Examples of Unusual Forms

316

Acute Megakaryohlastic Leukemia FAB M7

316

Epidemiology of Acute Lymphoblastic Leukemia

316

Prognosis of Acute Lymphoblastic Leukemia

317

Classifications of Acute Lymphoblastic Leukemia

317

Characteristics of Acute Lymphoblastic Leukemia

317

Clinical Signs and Symptoms

317

Laboratory Data

317

Special Identification Techniques

318

Treatment

319

Mixed Lineage Leukemia

319

Cytogenetic Analysis

319

Cytogenetic Analysis in Acute Myeloid Leukemia

319

Cytogenetics in Acute Lymphoblastic Leukemia

320

Principles of Special Cytochemical Stains

320

Sudan Black B Stain

321

Myeloperoxidase Stain

326

Periodic Acid-Schiff Stain

322

Esterase Stains

323

Phosphatase Stains

324

Monoclonal Antibodies

325

Immunophenotyping

325

Lymphoid

325

Other Surface Membrane Markers

326

Life-Threatening Emergencies

326

Infection

326

Bleeding

326

Leukemic Infiltration of Organs

326

Metabolic Abnormalities

326

Hyperieukocytosis

327

Treatment Options

327

Relapse

328

Stem Cell Transplant

328

Future Trends Vaccines

328

Chapter Highlights

328

Case Studies

329

Review Questions

333

Bibliography

335

20

Lymphoid and Plasma Cell Neoplasms

337

Mature B-Cell Neoplasms Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

337

Epidemiology

337

Etiology

337

Cytogenetics

338

Molecular Genetics

339

Staging and Prognosis

339

Clinical Signs and Symptoms

340

Laboratory Data

341

Treatment Options

341

Minimal Residual Disease

342

Hairy Cell Leukemia

342

Hairy Cell Leukemia Variant

343

Prolymphocylic Leukemia

344

Multiple Myeloma (Plasma Cell Myeloma)

344

Epidemiology

344

Etiology

344

Clinical Signs and Symptoms

344

Laboratory Data

344

Treatment

345

Waldenstro’m Primary Macroglobulinemia (Lymphoplasmacytic Iymphoma)

346

Epidemiology

346

Etiology

346

Clinical Signs and Symptoms

346

Laboratory Data

346

Treatment

347

Lymphomas

347

Relationship between Lymphomas and Leukemias

347

Characteristics

347

Categories

347

Pathophysiology