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CMWM633 WESTERN MEDICAL LABORATORY & IMAGING Credit hour: 3 Credits, 45 Hours Prerequisite: BS -525 Pathology Concurrent: BS-524 Microbiology Contents Composition of Blood Production of Blood cells Functions of Blood cells Hemostasis Hemogram(CBC) The lab test
LABORATORY & IMAGING
Credit hour: 3 Credits, 45 Hours
Prerequisite: BS-525 Pathology
Concurrent: BS-524 Microbiology
Average person circulates about 5L of Blood , of which 3L is plasma and 2L is cells. Plasma Fluid derives from the intestines and lymphatic systems and provides a vehicle for cell movement.
The cells are primarily produced by bone marrow and account for blood “solids”. Blood cells are classified as white cells (leukocytes),red cells(erythrocytes) and platelets(thrombocytes)
Hematopoiesis is a term describing the formation and development of blood cells.
Hematopoiesis begins as early as the 19th day after fertilization in the yolk sac of the embryo
Hematopoiesis in the bone marrow is called medullary hematopoiesis
Hematopoietic tissue includes tissues involved in the proliferation, maturation, and destruction of blood cells
(remanent of plate-hyaline cartilage
Causes the lengthwise growth)
Fibrous connective tissue
In certain pathologic states the bone marrow can increase its activity to 5-10X its normal rate.
The hematopoietic tissue may also become inactive or hypoplastic.
This may be due to:
Neutrophil Eosinophil Basophil
Netrophil Eosinophil Basophil
Injury to lining of bloodvessel exposes connectivetissue; platelets adhere
Platelet plug forms
Fibrin clot trapsblood cells
Platelet releases chemicalsthat make nearby platelets sticky
Clotting factors from:
Calcium andother factorsin blood plasma
FUNCTION:Determines plasminogen activity in persons with thrombosis or DIC, in these conditions excessive free plasmin is released to the plasma, In these situations antiplasmin is depleted and plasmin begins destroying components other than fibrin,including fibrinogen, factors V and VIII, and other factors
D-Dimer is an assay used to assess possible intravascular clotting. D-Dimer is a cleavage product of fibrin and is elevated in disseminated intravascular coagulation, in thromboembolic events and after surgery.
Consists of a WBC count , RBC count,hemoglobin (Hb) ,Hemotocrit (Hct), red blood cells indices and a platelet count.
A complete blood cell count (CBC) consists of a hemogram plus a differential WBC.
Place in tube
CELLULAR ELEMENTS 45%
Solvent forcarrying othersubstances
NUMBER(per mm3 of blood)
Erythrocytes(red blood cells)
Transport ofoxygen (and carbon dioxide)
Osmotic balance,pH buffering, andregulation ofmembranepermeability
Leukocytes(white blood cells)
Osmotic balance,pH buffering
Substances transported by blood
Nutrients (e.g., glucose, fatty acids, vitamins)
Waste products of metabolism
Respiratory gases (O2 and CO2)
Tests of White Blood CellsWhite Blood Cell Count (CBC)LeukocytesAre divided into two main groups :Granulocytes ; neutrophils,basophils,eosinophils also called PMNsAgranulocytes; lymphocytes and monocytes also called mononuclears
diagrams the entire process of extravasation from leukocyte rolling to migration into the tissues.
Neutrophils extravasate from blood vessels to the site of tissue injury or infection during the innate immune response
fight infections and defend the body by a process called phagocytosis, also produce, transport and distribute antibodies as part of the immune response to a foreign susbstance (antibody)
Leukocytosisoccurs in acute infections, in which the degree of increase of leukocytes depends on the severity of the infection. In certain disease (measles,pertussis,sepsis) the increase of leukocytes is so great that the blood pictures suggests leukemia ( in leukemia the leukocytosis is permanent and progressive)Other causes:Trauma or tissue injuryMalignant neoplasm's (bronchogenic carcinoma)Drugs (ether,epinephrine)Acute hemolysis
Leukopenia: WBC < 4000 mm3CAUSESViral infections, some bacterial infections, overwhelming bacterial infectionsHypersplenismBone Marrow depression caused by intoxication'sPrimary bone disorders: leukemia, pernicious anemia
Clinical ImplicationsLeukocytosis: WBC > 11,000mm3 It is usually caused by the increase of only one type of leukocyte, and it is given the name of the type of cell that shows the main increase.Neutrophilic leukocytosisLymphocytic leukocytosisMonocytic leukocytosisBasophilic leukocytosisEosinophilic leukocytosis
NEUTROPHILSNeutrophils, or neutrophil polymorphonuclear leucocytes, Acute Inflamatory response cell .40-70% WBC’c Phagocyitic . Multilobed.Large,sperical, azurophilic 1 granules(called lysosomes) contain hydrolytic enzymes,lysozyme,meyloperoxidase)
LYMPHOCYTESLymphocytes are produced within bone marrow (a primary lymphoid organ). If they achieve immune-competence within the bone marrow, they are known as B cells, or if in the thymus (also a primary lymphoid organ), they are known as T cells. Organized lymphoid tissue elsewhere is known as secondary lymphoid tissue, and includes lymph nodes, adenoids, tonsils and mucosa associated tissue (MALT). Small amount of pale cytoplasm,small ,round , densely staining nucleus. B lymphocytes produce antibodies. T lymphocytes manifest in the cellular immune response as well as regulate B lymphocytes and macrophages.
Lymphocytes are only slightly larger than red blood cells (small lymphocytes) and they have a relatively large nucleus:cytoplasm ratio.
B Lymphocyte: Part of the humoral immune response.Arises from stem cells in bone marrow.Matures in marrow.Migrates to the peripheral tissue (follicles of lymph nodes,white pulp of spleen,unencapsulated lymphoid tissue.When an Antigen is encountered, B cells differentiate into plasma cells and produce antibodies.Has a memory, Functions as antigen presenting cell via MHCmajor histocompatibility complex
Plasma cells (fully differentiated B cells) are similar in appearance to lymphocytes, even though they are not normally present in this blood test measures the number of lymphocytes in the peripheral blood.Off-center nucleus, clock face chromatin distribution, abundant RER and well developed Golgi apparatus.Multiple Myeloma is a plasma cell neoplasm
The T cells the master immune cells include CD4+ helpers T cells CD8+ suppressor T cellsMediates cellular immune response,Originates from stem cells in the bone marrow but matures in the thymus.T cells differentiate in:1- cytotoxic T cells (MHC I,CD8) 2-helper T cells,delayed hypersensitivity Tcell.MHC=Mayor histocompability complex
Clinical Implications:1-Inmmunosuppressive drugs therapy usually decreases lymphocyte total2-Patients with an absolute helper T lymphocyte count <200mm3 are at greatest risk for developing clinical AIDS3-Decrease T cells occur in congenital immunodeficincy(DiGeorge syndrome,thymic hypoplasia)4-A marked increase in B cells occurs in lymphoproliferative disorders (chronic lymphocyitc leukemia)
Lymphopenia < 1000cells/mm3ChemotherapyAfter administration of ATCHIncrease loss of G-I tract owing to obstruction of lymphatic drainageAplastic anemia
BASOPHILSBasophils are non-phagocytic cells which, when activated, release numerous compounds from the basophilic granules within their cytoplasm. They play a major role in allergic responses, particularly type I hypersensitive reactions.
MONOCYTESMonocytes circulate in the peripheral blood prior to emigration into the tissues. Within certain organs they have special names, e.g. in liver they are known as Kupfer cells, in brain as microglia, in kidney as mesangial cells, and in bone as osteoclasts. Elsewhere they are referred to as tissue macrophages. Phagocytosis is mediated by macrophages and polymorphonuclear leucocytes
EOSINOPHILSThese cells have the purpose of giving large parasites such as helminths, a hard time. The eosinophils release various substances from their eosinophilic granules. The granule contents are capable of damaging the parasite membrane.
How do I remember the
60 + 30 + 6 + 3 +1
(i.e., 60% neutrophils, 30% lymphocytes, 6% monocytes, 3% eosinophils & 1% basophils)
Acute Leukemias Chronic Leukemias
short and drastic courses
More mature cells
midlife age range
longer,less devastating course
responsive to therapy
SBB STAINS (Sudan Black B)The SBB stain aids in differentiation of the immature cells of acute leukemias, specially acute myeloblastic leukemias (AML). The SBB stains a variety of fats and lipids that are present in myeloid leukemias but not present in the lymphoid leukemias.
Periodic Acid-Schiff (PAS) Stain.The PASS stian aid in the diagnosis of acute lymphoblastic leukemias (ALL) Early myeloid precursors and erythrocyte precursors are negative. As granulocytes mature,they increase in PAS positivity, whereas mature RBC’s stay negative. The PAS stain cannot be used to distinguish between ALL and AML or between benign and malignant lymphocytic disorders.
Terminal Deoxynucleotidyl Transferase (TDT)The thyme is the primary site of TDT-positive cells, and TDT is found in the nucleus of the more primitive T cells. TDT is increase in >90% of cases of ALL of childhoodTDT positive blasts are predominant in some cases of chronic myelogenous leukemia (CML) , relating to the development of an acute blast phase.
RED BLOOD CELL COUNT(RBC,Erythrocyte count)Many test look at the red blood cells:their number and size,amount of Hb , rate of production and percent composition of the blood.The red blood cell count(RBC), hemotocrit(Hct) and hemoglobin(Hb) are closely related ,the same conditions cause an increase (or decrease) in each of these indicators
The main function of the RBC is to carry oxygen from the lungs to the body tissues and to transfer dioxide from the tissues to the lungs , by the Hb in the RBC which combines easily with oxygen and carbon dioxide. This test is an important measurement in the evaluation of anemia or polycytemia,determines the total number of erythrocytes in a microliter of blood.
Hematocrit (Hct)The word means separate blood , the mechanism of the test separates by centrifugation the plasma and the blood cells.Indirectly measures the RBC mass, important for determination of anemia or polycythemia.NormalWomen; 36%-48%Men 42%-52%
Hemoglobin (Hb)Hb the main component of erythrocytes , serves as the vehicle for the transportation of O2 and C02. It is composed of amino acids that form a single protein called globulin and a compound called heme, which contains iron atoms and the red pigment porphyrin. It is the Iron pigment that combines with oxygen and gives blood its characteristic red color
The Hb determination is part of the CBC. It is used to screen for disease associated with anemia, to determine the severity of anemia, to monitor the response to treatment for anemia and to evaluate polycytemia.
Decreased Hb levels are found in anemic states, the Hb must be evaluated with the Htc and the RBCIron deficiencyliver diseasehemorrhagehemolytic anemias
MCV : the mean corpuscular volume
MCHC: the mean corpuscular concentration
MCH: the mean corpuscular hemoglobin
The RBC indices are used in differentiating anemias. When they are used together with an examination of the erythrocytes on the stained smear, a clear picture of the RBC morphology may be ascertained.In deficient states anemias can be classified by cell size as macrocytic,normocytic,microcytic, or by cells size and color , as microcytic hypochromic.
MCVIndicates the red blood cell sizenormal: small<82um3 or larger >100um3MCV= Hct% x 10 / RBCMacrocytic: (MCV>100) Megaloblastic (B12-Folic acid) Microcytic: (MCV<80) Iron Deficiency Thalasemias, lead poisoningNormocytic,normochromic: enzyme defects(G6PD def-) , RBC membrane defects, bone marrow disorders, Autoinmmune hemolytic anemias, anemias of chronic disease.
MCHC (Mean Corpuscular Hemoglobin Concentration)Measures the average concentration of Hb in RBC’s , used for monitoring therapy for anemias.Normal: 32-36g/dLMCHC=Hb x 100/Hct%
MCH (Mean Corpuscular Hemoglobin)Is a measure of the average weight of Hb per RBC , this index is of value in Dx severly anemic patients.Normal:26-34pg/cell
“Anemia is decreased red cell mass affecting tissue oxygenation”
* Low Hb <13.5 (males), <11.5 (females)
(Deficiency, Marrow disorder, Blood loss & Hemolytic)
AnemiasMicrocytic MCV<80Iron deficiencyThalassemiasLead poisoningMacrocytic MCV>100Megaloblastic:B12/folate def.Drugs that block DNA: Methotrexate-MTXNormocytic-normochromic:Enzyme defects,RBC membrane defects,bone marrow disorders, hemolytic,chronic disease.
MEGALO B LASTIC
M I CROCYTIC
Reticulocyte Count.Young immature nonnucleated RBC , normally a small number of these cells are found in the circulating blood , it is used to differentiate anemias caused by bone marrow failure from those caused by hemorrhage or hemolysis , to check the effectiveness of treatment in pernicious anemia and folate and iron deficiency, to asses the recovery of bone marrow function in aplastic anemia, and to determine the effects of radioactive substances on exposed workers.
Normal: 0.5%-1.5% of total erythrocytes.Increased : means that increase production RBC is occurring as the bone marrow replaces cells lost or prematurely destroyed. Identification of reticulocytosis may lead to the recognition of an otherwise occult disease , such as hidden chronic hemorrhage or unrecognized hemolysis(eg sickle cell anemia, thalassemia).
Fetal Hemoglobin (hbF)Is a normal Hb manufactured in the RBCs of the fetus and infant; it makes up to 50% to 90% of the Hb in newborn.The portion of the Hb in the newborn is made up to of HbA1 and HbA2. In adult types under normal conditions the manufacture of fetal Hb is replaced by the adults types during the first year of life, but if the FHb persists and constitutes more than 5% of the Hb after 6 moths an abnormality should be expected.
Hemoglobin A2HbA2 levels have special application in the diagnosis of beta thalassemias trait,which may be present even though the peripheral blood smear is normal. This measurements is used in the investigation of hemolytic anemias for hemoglobinopathies especially thalassemia (beta thalassemia)
Hemoglobin S (sickle cell test)Sickle cell disease is a term for a group of hereditary blood disorders,caused by an abnormality of the Hb,the red protein in the red blood cell that carries oxygen from the lungs to the tissues. People with sickle cell disease make abnormal Hb, hemoglobin S , this cells do not last as long as normal red blood cells, they become rigid and take a sickle or crescent shape, they are not flexible enough to squeeze through the vessels, resulting in blood vessels being blocked damaging tissues and organs.Normal:not present.
MyoglobinIs the oxygen binding protein of striated muscles.It resembles Hb but is unable to release oxygen except in extremely low tension, injury of the muscle results in the release of the oxygen, Myoglobin is not tightly bound to protein and is rapidly excreted in urine, It is used as an early marker of muscle damage in myocardial infarction and to detect injury of the skeletal muscle
Platelet CountMean Platelet Volume(MPV)Platelets are the smallest of the formed elements in the blood ,they are nonnucleated round or oval ,dish-shaped structures, Platelet activity is necessary for the blood clotting,vascular integrity and vasoconstriction,and the adhesion and aggregation activity .Thorombocyte development takes place in the bone marrow life is about 7.5 days
PANIC VALUES , a decrease in platelets to <20X10 3/mm3/L is associated with a tendency for spontaneous bleeding prolonged bleeding time, pethechie and ecchymosis.Platelets count >50x10 3/mm3 are not generally associated with spontaneous bleeding.
MPVIs valuable in assessing bleeding disorders that occur in thrombocytopenia,uremia,liver disease or malignancies and for monitoring the course of disease associated by the bone marrow failure.The mean platelet volume is sometimes ordered in conjunction with a platelet count it indicates the uniformity of size of platelets population.It is used for differential diagnosis of thrombocytopenia.ValuesNormal: adults:140-400x 10 3/mm3
Intrinsic pathway Extrinsic Pathway
XI XI a tissue factor
IX IX a VII VII a
X X a
II II a
FIBRINOGEN FIBRIN fibrin products
Procoagulant-antigenic portions VIII
Platelet AggregationIt is used to evaluate congenital qualitative functional disorders of adhesion,release ,or aggregation. It is rarely used to evaluate acquired bleeding disorders.
Prothrombin time(PT) is used to assess the extrinsic pathway Prolongation the PT is seen with warfarin use,vitamin K deficiency and liver disease.Monitors Warfarin Tx
Partial Thromboplastin time (PTT) is used to assess the intrinsic system.It is prolonged during heparin use, in hemophilia A,B and von Willebrand’s disease.Monitors Heparin Tx
Platelet count bleeding time PT PTT
hemophilia A (factor VIII)
hemophilia B (factor IX)
Von Willebrands (VIII)
Vitamin K def(1972)