WHITE BLOOD CELLS & IT’S DISORDERS

1. WHITE BLOOD CELLS & IT’S DISORDERS PRESENTED BY DEEPA KC GUIDED BY DR MAJI JOSE DR VISHNU PRABHU DR PAVITRA DR SONIA

2. WHITE BLOOD CELLS • It is the another class of cells of blood • Major function defence the body against microbes by 1. phagocytosis 2. immune mechanism • Staining of peripheral blood by Romanowsky’s stain. this stain have 2 comopent Azure B & Eosin Y

3. Azure B TrimethylThionine/ blue methionine it is basic & combine with acidic materials. It stain nucleus blue. • Eosin Y tetra bromoflurescein it is acidic, red dye, stain basic material pink. • Modification of Romanowsky’s stain Leishman’s – popular in india Wright stain – popular in USA Jenner – simple procedure Giemsa – complicated procedure

4. PHYSIOLOGICAL VARIATION • AGE: in infants WBC count is 20,000/cu.mm in children the WBC count is 10,000-15,000/cu.mm in adults the WBC count is 4,000-11,000/cu.mm. • SEX: WBC is more in males. ↑ in pregnancy and menstruation – females. • DIURNAL VARIATION : minimum in early morning and maximum in afternoon. • EXERCISE : WBC is ↑ • SLEEP : WBC is ↓ • EMOTIONAL VARIATION: is ↑ during anxiety.

5. WBC COUNT • TOTAL WBC COUNT – 4000- 11000/cumm • DIFFERENTIAL COUNT – %wise distribution of the type of cell 100 WBC eg : 60% neutrophil 60 number neutrophil in 100 WBC • ABSOLUTE COUNT – 3% eosinophil 5000× 3/100 = 150 eosinophil/μl

6. WBC COUNT WBC DIFF COUNT ABSOLUTE LIFE SPAN VALUE/CU.MM Neutrophils 50-70% 3000-6000 2-5dys Eosinophils 2-4% 150-450 7-12dys Basophils 0-1% 0-100 12-15dys Monocytes 2-6% 200-600 2-5dys Lymphocytes 20-30% 20-30 ½-1day

7. Haemopoesis

8. SIZE OF WBC

9. Types of WBC’s AGRANULOCYTES & GRANULOCYTES

10. GRANULOCYTES • Granulocytes are the category of leukocytes that contain granules within the cytoplasm & have lobed nucleus. • Formed bone marrow • Granulocytes include: Neutrophils, Eosinophils, Basophils.

11. AGRANULOCYTE • Agranulocytes are the category of leukocytes that do not contain granules. • Agranulocytes are produced by the lymph nodes, spleen, thymus, and other lymphoid tissue. • There are two types of agranulocytes: Lymphocytes, and Monocytes.

12. NEUTROPHIL • 60-70% of all leukocytes , most abundant of WBC’s • produced by bone marrow • function 1. emigrate from blood vessel to tissue , It reach to bacteria by chemotaxis , phagocyte them & kill them by different enzymes. 2. facilitation of inflamation • 10 – 14 μm size • 2-5 lobes in nucleus .

14. Young neutrophil have less no of lobes , as the age increases no of lobes also increases. Young neutrophil with 2- 3 lobes aeen in case of infection , neutrophil with > 5 lobes seen in vit B12 / foliate defi anemia. • Emigration of neutrophil facilitated by lobed nucleus. • Granules amphophilic / neutrally stained 2 types – a) azurophilic/ primary granule - less in no - seen at the stage of promyelocyte - contain acid hydrolase & myeloperoxidase - also contain powerful broad spectrum antimicrobial polypeptide defensin

15. b) secondary granule - numerous - appear at myelocyte stage - contain lactoferrin - produce free radicle like H2O2 - produce substances helps in chemotaxis. • Coarse cytoplasmic granule seen during infection known as toxic granule. • Neutrophil is phagocytic , but it is smaller than macrophage, so it is called microphage . It is the first defence soldier arrived at the site of microbial invasion, so previously it is known as 1st line of defence.

16. EOSINOPHILS • 1-4% of the WBC's • 10 – 15 μm size. • nucleus is bilobed , look like spectacle. • Cytoplasmic granule is eosinophilic , it stain red by leishman stain. • Granule contain - MBP ( major basic protein) contain histaminase which inhibit histamine - eosinophilperoxidase – produce H2O2 , activate mast cell leads to inflammation. - cationic protein – inactivate heparine

18. Eosinophilia seen in - infection by parasites hookworm , filaria - allergies and asthma. • It is weak in phagocytosis, it kills by H2O2 release & histaminase activity.

19. BASOPHIL • rare granulocytes that are responsible for the symptoms of allergies, including inflammation. • Basophil present in blood , but in tissue another kind of cell present called mast cell. Appearance & function of both is same. • < 1% of WBC • Size of 10-12μm • Contain coarse basophilic granule. • Granule contain histamine & heparin & small amt of bradykinin & seratonin

20. Basophils & mast cell combine with IgE , results in degranulation , leads to conditions such as allergy , anaphylactic shock.

21. MONOCYTE • Largest circulating WBC • 2- 8% 0f WBC • Size of 12-20μm • Nucleus is not lobed & no granules in cytoplasm • It born in RBM, then enter in to circulation with in 48-72hr, then emigrate in to tissue. In tissue monocyte converted in to tissue macrophage. • Function - phagocytosis - release many cytokines - play key role in lymphocyte mediated immunity known as 2nd line of defence

23. LYMPHOCYTE • 25% of circulating WBC • By leishman’s stain 2 type - small lymphocyte - large lymphocyte • Having large nucleus & little scanty cytoplasm • There are 2 type T lymphocyte B lymphocyte It can’t differentiate by leishman’s stain. • T lymphocyte play role in cell mediated immunity . B lymphocyte play role in humoral immunity.

25. 4 types of Tcell 1) Helper T cell – a) helps in growth & proper functioning of cytotoxic T cell , suppressor T cell B lymphocyte , macrophage b) produce many chemicals such as IL-3, TGF, granulocyte colony stimulating factor. Cytokines produce by lymphocyte known as lymphokines 2) cytotoxic T cell – it kills microbes , cancer cells, reject tissue transplanted from different person. They kill Ag through perforins. It perforate the membrane of Ag

26. 3) Suppressor T cell – it regulate the immune response. 4) memory T cell – after the removal of Ag, the specific acquired immune mechanism declines, but few T lymphocytes persist in the lymphnodes for years called memory T cell . When reinfection by the same microbes occure in later life, these cells get activated & remove the microbes. B Lymphocyte main function is synthesis of antibody . After an antigenic challenge , the specific clone of B lymphocytes are converted in to lymphoblast, later it become plasma blast. Plasma cell produce antibody.

27. WBC DISORDERS • 1) Leukocytosis • 2) Leukopenia - Agranulocytosis - Cyclic Neutropenia - Chediak – Higashi Syndrome • 3) Infectious Mononucleosis • 4) Leukaemoid Reaction • 5) Leukaemia - Acute - Chronic

28. I. LEUKOCYTOSIS

30. II. Leukopenia 1. Agranulocytosis 2. Cyclic neutropenia 3. Chediac – Higashi syndrome

31. AGRANULOCYTOSIS • Synonyms: Neutropenia, Granulocytopenia , agranulocytic angina, malignant leaukopenia Characterized by decreased number of circulating granulocytes <1500/cumm CLASSIFIED Primary agranulocytosis Secondary agranulocytosis

32. ETIOLOGY • Primary: associated with many syndrome – etiology is not known -chediakhigashi syndrome. -kostmann syndrome • Secondary: associated with drugs anti inflammatory: penicillamine. Anti thyroid drugs: carbimazole, propylthiouracil. Anti arrhythmic: quinidine Anti hypertensive: captopril, enalapril Anti malarial: dapsone, sulfadoxine Anti convulsant : sodium valproate. Antibiotics: penicillins , cephalosporins

33. Mechanism that cause agranulocytosis is not known. In drug induced , it act as a haptan & induce antibody formation , which destroy the granulocyte or form immune complex which bind WBC & destroy them. • Autoimmune neutropenia is due to anti neutrophil antibodies . • Kostmann syndrome is - congenital neutropenia - mutation in granulocyte colony stimulating factor - myelodysplasia in early infancy with recurrent infection

34. CLINICAL FEATURE • At any age, mainly in adult , women. • Mainly affect health professionals coz they can access to offending drugs & use drug samples injudiously. • Bacterial infection depending upon degree of neutropenia • Fever is the first manifestation with <500cells/cu.mm of blood • sore throat, weakness, skin become pale & anaemic • Most charecteristic feature is infection of oral cavity& through out GIT, UT, RT • If proper Rx is not given , leads to sepsis & death with in a week

35. ORAL MANIFISTATION • necrotic ulcer present in oral mucosa, tonsils, Pharynx, gingiva and palate with no purulent discharge. • Ulcer covered by gray/black membrane. Less haemorrhage & pus. • No sign of inflammation around the lesion. • Excessive salivation • Oral surgical procedure & tooth extractions are contraindicated. Histological features • Ulcerated epithelium • Lackes of development of granular leukocyte, no PMN against the bacteria in tissue. • Rapid destruction of supporting tissue of teeth. • Necrosis of tissue start at gingival sulcus & spead in to free gingiva & pdl.

36. Lab finding • WBC count <500cells/cu.mm with complete absence of neutrophils & other granulocyte. • RBC and Platelets count is normal. • Bone marrow shows absence of granulocytes, but myeloblast & promyelocytes are present . Basic defect is arrest in cell maturation. • Microscopically– necrosis of gingiva beginning in sulcus is seen.

37. Management • Not specific, withdrawal of causative drug and administration of antibiotics to control infection. • Death is due to massive infection. • Prognosis is good , if identifying causative factor. • Agranulocytosis due to viral disease is self limiting , have good prognosis.

38. CYCLIC NEUTROPENIA Synonymsperiodic neutropenia, periodic agranulocytosis , cyclic agranulocytic angina • Unusual form of agranulocytosis characterized periodic/cyclic deminutation of PMNs. • Bone marrow maturation arrest. • It spontaneously regress & recur in rhythmic pattern. ETIOLOGY • autosomal dominant cyclic neutropenia is caused due to mutation of gene ELA2

39. Clinical Feature • Patient manifest a cyclic pattern of neutropenia after every 21days persisting for 3-5days. • Infants and young children • Fever, malaise, sore throat and regional lymphadenopathy. • Neutrophil count is low for short period of time, so no significant bacterial infection . Oral Manifistation • Gingivitis and stomatitis with ulceration corresponding to the period of neutropenia. • Ulcer persist for 14 days & heals with scarring. • radiographic manifistation is mild to severe loss of superficial alveolar bone. Also called prepubertalperiodontitis.

40. Lab findings • WBC differential count is normal for 21days , for 3-5dys neutrophil count is declined which is compensated by increased monocytes and lymphocytes. Management • No specific Rx • Prognosis is better than agranulocytosis. • Pt may die due to infection in severe case.

41. CHEDIAK-HIGASHI SYNDROME Synonyms :Beguezcèrsar syndrome ETIOLOGY • Rare autosomal recessive immunodeficiency disorder characterized by abnormal intracellular protein transport. • Defect in LYST/ CHS 1 gene located on 1q42-43 is lysosomal regulator. • It affect synthesis of - lysosome - dense body of platelet - azurophilic granule of neutrophil - melanosomes of melanocyte • Autophagocytosis of melanosome results in oculocutaneous albinism

42. CLINICAL FEATURE • seen after birth/children younger than 5yrs. • immune deficiency, occulocutaneousalbunism, recurrent infection with neutropenia, impaired chemotaxis, bleeding due to platelet defect. • Terminal phase charecterized by non malignant lymphohistiocytic lymphoma of multiple organs that occure in 80% of case. It is precipitated by Epstein-Barr viral infection. results in anaemia, bleeding,infection & death. • Infection secondary to abnormal PMN. • Very few pt live to adult hood have peripheral neuropathy. ORAL MANIFISTATION • Ulceration , gingivitis, glossitis and breakdown of periodontium due to defective leukocytes.

43. Lab finding • Peripheral smear reveals: giant abnormal granules in circulation leukocytes— dohles bodies. This is the hallmark of this syndrome. It represent abnormal lysosomes. • Ultra structurally – viable dividing bacteria along with abnormal granules are found in cytoplasm of periodontal PMN. Management • No specific Rx • Death occure before the child reaches the age of 10yrs.

44. III) INFECTIOUS MONONUCLEOSIS Synonyms: glandular fever, kissing dieases. • It is described as mononuclear leukocytosis in reaction to acute infection. charecterized by fever , pharyngitis, adenopathy. • Early it is termed Drusenfieber • Occure in children & young adult, no sex prediction. • EB virus transmit through body secretions & saliva, so it is known as kissing disease. • EB virus persist in saliva for 18 month following onset of the disease.

46. Clinical Feature • Sore throat, fever, headache, chills cough nausea vomiting and lymphadenopathy. • Splenomegaly and hepatitis, pharyngitis , tonsilitis. • Cervical lymph node involvement.

47. Oral Manifistation • No specific oral manifestations. • Acute gingivitis and stomatitis with ulceration. • White gray membrane in various area. • Petechial hemorrhage of soft palate several in number. It appear few days after prodromal symptoms. It is the early clinical diagnostic sign. • It is 12-100 in number. Lesion persist for 3-11dys. Gradually fades.

48. INVESTIGATION AND DIAGNOSIS • Peripheral blood smear shows atypical lymphocytes. It have horse-shoe shaped/ intented nuclei with dense chromatin & vacuolated cytoplasm. Also known as mononucleosis cell / downey type cell . • Increase in hetrophilantibody titer to 1:4096 – paulbunnell test. • EBV nuclear antibodies appears after 1-2mths and persist through out life. • EBV infected B Cell undergo polyclonal activation & proliferation, it secrete IgM antibody & later produce IgG , which present through out life .

49. Management -Rest and adequate diet. -Short term steroids. -Disease generally run its course in 2-4wks with less complications

50. IV) LEUKAEMOID REACTIONS • It is reactive leucocytosis in peripheral blood, resembling that of leukaemia in a subject who doesn’t have. • Clinical feature of leukaemia such as splenomegaly, lymphadenopathy, hemmorrhage are usually absent. • 2 type - myeloid leukaemoid reaction - lymphoid leukaemoid reaction