HEMATOPOIESIS

STAGES OF HEMATOPOIESIS
MESOBLASTIC HEPATIC MEDULLARY
19th day of 5th to 6th week 4th or 5th month of
Starts at
gestation of gestation gestation
Fetal liver
(thymus, spleen,
Site Yolk sac Bone marrow
kidneys, lymph
nodes)
Vascularity Intravascular Extravascular
Erythroblasts,
Primitive
Product Granulocytes,
erythroblast
Monocytes
Embryonic
Hb
(Gower-1, Gower-2, Hb F Hb F, Hb A
produced
Portland)

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 MONOPHYLETIC THEORY OF HEMATOPOIESIS
• PROGENITOR: not morphologically identifiable
• PRECURSOR: morphologically identifiable

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

• SURFACE MARKERS
Cell Surface Markers
Hematopoietic stem cell CD34
Myeloid (CFU-GEMM) CD33
Erythroid (CFU-E) CD71
T-Lymphoid (Pro-T cell) CD5 / CD7
B-Lymphoid (Pro-B cell) CD10

• GROWTH FACTOR
Growth Factor Purpose
G, M-CSF Pan-myeloid growth factor
IL-3 Multipotential colony stimulating factor
IL-6 Activating factor
IL-11 Formation of B cells and megakaryopoiesis
Thrombopoietin Maturation of megakaryocytes and platelet production
Erythropoietin Growth and differentiation of erythroid precursors

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 MORPHOLOGIC TREND
Erythroblast Mature stage
Cell size Larger Smaller
N:C ratio High Low
Nucleoli Present Absent
Fine, uniform Coarse, clumped,
Nuclear chromatin
homogenous condensed
Color of cytoplasm Blue Pink

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC MATURATION SERIES NOMENCLATURE
BM transit
Stage N:C Other comments
time
(+) globin production
Rubriblast / Pronormoblast 8:1 24 hrs
starts
Prorubricyte / (-) last stage with
6:1 24 hrs
Basophilic normoblast nucleolus
(+) Hb synthesis starts
(+) pink cytoplasm
Rubricyte /
4:1 30 hrs appears
Polychromatic normoblast
(-) last stage with
mitosis
Metarubricyte / (-) last stage with
1:2 48 hrs
Orthochromic normoblast nucleus
(-) last stage of Hb
Polychromatic erythrocyte 24-48 hrs
synthesis
Erythtocyte
JENNIE LIZA OCAMPO HEMATOLOGY: RBC
 DESTRUCTION OF RBC
Extravascular Intravascular
Hemolysis Hemolysis
% 80-90% 10-20%
Reticuloendothelial
Mechanism system (RES), RBC fragmentation
Macrophage-mediated
¯ haptoglobin
Lab findings ­ serum bilirubin ¯ hemopexin
(excessive hemolysis) ­ urine urobilinogen Hemoglobinuria
Hemosiduria

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC METABOLIC PATHWAYS
Pathway Enzyme Product Other comments
• Anaerobic glycolysis
Pyruvate,
Embden- Hexokinase, • Major source of ATP
ATP (2 (90%)
Meyerhof (EMP) PK, LDH
molecules) • Glucose ® pyruvate
• Aerobic glycosis
Hexose-
NADPH, • Alternative glycolysis (5-
Monophosphate G6PD
pentose 10%)
(HMP/PPP) • Reduces glutathione
Methemoglobin Cytochrome Ferrous • Prevents methemoglobin
Reductase B5 reductase iron (Fe2+) formation
• ­ 2,3-DPG = ¯ O2
Rapaport-
2,3-DPG affinity to Hb = ­ O2
Leubering
delivery to tissues

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 HEMOGLOBIN
• Heme synthesis = mitochondria
• Globin synthesis = ribosome

Hb Assembly Hb Type Globin chains

Gower-1 2 epsilon, 2 zeta
Intrauterine /
Gower-2 2 epsilon, 2 alpha
Embryonic
Portland 2 gamma, 2 zeta
Hb F (60-90%) 2 alpha, 2 gamma
Newborn
Hb A (10-40%) 2 alpha, 2 beta
Hb A (95%) 2 alpha, 2 beta
>2 years old Hb A2 (<3.5%) 2 alpha, 2 delta
Hb F (1-2%) 2 alpha, 2 gamma

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 HB-O2 DISSOCIATION CURVE
Shift to the Left Shift to the Right
(¯P50 value) (­ P50 value)
pCO2
Temperature
H+ DECREASED INCREASED
2,3-DPG
O2 delivery to tissues
O2 affinity to Hb
INCREASED DECREASED
pH

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 DYSHEMOGLOBINS
Methemoglobin Carboxyhemoglobin Sulfhemoglobin
(Hi) (HbCO) (SHb)
Pattern of
Acquired/ inherited Acquired Acquired
inheritance
Toxic effects
Effects Cyanosis, dyspnea
(20-30% levels)
Color of
Chocolate brown Cherry red Mauve lavender
blood
Reducing agents:
Removing source,
Treatment methylene blue, Avoidance
O2 therapy
ascorbic acid
• Sulfur atom at
Other • 240x affinity to Hb heme pyrrole
• Ferric iron (Fe3+)
comments than O2 ring
• Irreversible

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

• CYANMETHEMOGLOBIN METHOD OF HEMOGLOBIN DETERMINATION:
Cause of Specimen Turbidity Remedy / Correcition
High WBC count (20 x 109/L) Centrifuge reagent specimen solution
High platelet count (>700 x 109/L) and measure supernatant
Make a 1:1 or 1:2 dilution with distilled
Presence of Hb S or Hb C
water then multiply result y 2
Lipemic sample Use patient/reagent blank

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC MORPHOLOGICAL ABNORMALITIES
• ANISOCYTOSIS = variation in cell size
• ANISOCHROMIA = variation in Hb content
• POIKILOCYTOSIS = variation in cell shape

ANISOCYTOSIS
MCV Cell diameter
Microcytic <6 µm <80 fL
Normocytic 6-8 µm 80-100 fL
Macrocytic >8 µm >100 fL

ANISOCHROMIA
Central pallor MCHC
Hypochromic Larger <32%
Normochromic 1/3 32-36%
Hyperchromic Smaller / Absent >36%
JENNIE LIZA OCAMPO HEMATOLOGY: RBC
 POKILOCYTOSIS
Description Significance
Macroovalocyte Large, oval Megaloblastic anemia
Spherocyte / Hereditary spherocytosis,
No central pallor
Bronze cell AIHA, severe burns
Severe liver disease,
Acanthocyte /
Abetalipoproteinemia,
Thorn cell / Irregular projections
McLeod syndrome,
Spur cell
PK deficiency
Echinocyte / Regular projections, Uremia, ESRD,
Burr cell crenated PK deficiency
Obstructive jaundice,
Target cell / Dark stain in center and Thalassemia,
Codocyte periphery Hemoglobinopathies,
Hb C disease
Hereditary stomatocytosis,
Stomatocyte /
Slit-like area on center Acute alcoholism,
Mouth cell
Rh null syndrome
JENNIE LIZA OCAMPO HEMATOLOGY: RBC
 Description Significance
Hereditary elliptocytosis,
Elliptocyte Egg-/cigar-shaped
IDA, Thalassemia major
Schistocyte / MAHA, DIC, HUS, TTP,
Fragmented RBCs
Helmet cell severe burns
Primary myelofibrosis,
Dacryocyte / Thalassemia,
Pointed end
Tear drop cell Myelophthisic anemia,
Megaloblastic anemia
Sickle cell / Sickle cell anemia,
Crescent-shaped
Depranocyte Sickle cell beta-thalassemia

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC INCLUSIONS
Inclusion Content Description Significance
Diffused Hemolytic anemia,
Bluish tinge
basophilia / RNA Post-treatment for
throughout cytoplasm
Reticulocyte megaloblastic anemia
Lead poisoning,
Megaloblastic anemia,
Coarse Dark blue-purple Thalassemia,
Precipitate
basophilic punctuate granules Hemoglobinopathies,
d RNA
stippling MDS, Metal poisoning,
Pyrimidine-5-nucleotidase
deficiency
G6PD deficiency,
Denatured Dark blue-purple in
Heinz bodies Unstable Hb,
hemoglobin supravital stain
Oxidant drugs
Mitotic
Megaloblastic anemia,
Cabot rings spindle Figure-eight inclusion
MDS
remnants
JENNIE LIZA OCAMPO HEMATOLOGY: RBC
 Inclusion Content Description Significance
Sideroblastic anemia,
Pappenheimer Thalassemia,
bodies / Non-heme Iron deposits on Hemoglobinopathies,
Siderotic iron periphery Megaloblastic
granules anemia,
Hyposplenisms, MDS
Precipitated
Hb H
ß-globin “Golf-ball” appearance Hb H disease
inclusion
chains
“Bar of gold”
Hb C crystals Hb C disease
appearance
Hb SC “Washington
Hb SC disease
crystals monument” appearance
NRBC with iron
Ringed Non-heme Sideroblastic anemia,
deposits around
Sideroblast iron MDS
nucleus

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC INCLUSIONS

DIFFUSED BASOPHILIA BASOPHILIC STIPPLING HEINZ BODIES

PAPPENHEIMER BODIES CABOT RING Hb H INCLUSION

Hb C CRYSTAL Hb SC CRYSTAL RINGED SIDEROBLAST

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 RBC INDICES
Index Normal value Formula
𝑯𝒄𝒕 (%)𝒙 𝟏𝟎
MCV 80-100 fL 𝑴𝑪𝑽 =
𝑹𝑩𝑪 𝒄𝒕.
𝑯𝒈𝒃 𝒙 𝟏𝟎
MCH 26-32 pg 𝑴𝑪𝑯 =
𝑹𝑩𝑪 𝒄𝒕.
𝑯𝒈𝒃
MCHC 32-36% or g/dL 𝑴𝑪𝑯𝑪 = 𝒙𝟏𝟎𝟎
𝑯𝒄𝒕
𝑺𝑫 𝒐𝒇 𝒄𝒆𝒍𝒍 𝒔𝒊𝒛𝒆
RDW 11.5-14.5% 𝑹𝑫𝑾 = 𝒙 𝟏𝟎𝟎
𝑴𝑪𝑽
% 𝒓𝒆𝒕𝒊𝒄 𝒙 𝑹𝑩𝑪 𝒄𝒕.
ARC 𝑨𝑹𝑪 =
𝟏𝟎𝟎
𝒄𝒐𝒓𝒓𝒆𝒄𝒕𝒆𝒅 𝒓𝒆𝒕𝒊𝒄
RPI 𝑹𝑷𝑰 =
𝒎𝒂𝒕𝒖𝒓𝒂𝒕𝒊𝒐𝒏 𝒕𝒊𝒎𝒆

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 IRON COMPONENTS
Type Component %
Hemoglobin 68%
Functional Myoglobin 10%
Enzymes 3%
Storage Ferritin and hemosiderin 18%
Transportation Plasma <1%

Type Normal value

Serum iron 50-160 µg/dL
TIBC 250-400 µg/dL
% transferrin saturation 20-55%
Serum ferritin 40-400 ng/mL
Soluble transferrin receptor (sTfR) 1.15-2.75 mg/L
Zinc protoporphyrin (ZPP) <80 µg/dL

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 ANEMIA
MORPHOLOGICAL CLASSIFICATION OF ANEMIA
• MICROCYTIC ANEMIA –– “ITAS”
® Iron deficiency anemia
® Thalassemia
® Anemia of chronic inflammation
® Sideroblastic anemia
• MACROCYTIC ANEMIA
® Megaloblastic anemia: Vit B12 deficiency, Folic acid deficiency
® Non-megaloblastic anemia: Liver disease, alcoholism, BM failure, reticulocytosis
• NORMOCYTIC ANEMIA –– “AHA”
® Acute blood loss anemia
® Hemolytic anemia
® Aplastic anemia

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

• MICROCYTIC ANEMIA
Serum Transferrin Serum FEP/
TIBC sTfR
Iron sat. ferritin ZZP
IDA ¯ ­ ¯ ¯ ­ ­
ACI ¯ ¯ ¯ ­ ­ N
Thalassemia N N N N N N
Sideroblastic
­ ¯ ­ ­ ­ N
anemia

® THALASSEMIA
Type of # of def.
Clinical syndrome Comments
Thalassemia genes
α-thalassemia silent carrier 1 No abnormality
α-thalassemia minor 2 Asymptomatic, mild anemia
Alpha
Hb H disease 3 Chronic hemolytic anemia
Hb Bart – Hydrops fetalis 4 Fetal or neonatal death
ß-thalassemia silent carrier 1 No abnormality
ß-thalassemia minor 2 Asymptomatic, mild anemia
Beta
Thalassemia intermedia 3 Non-transfusion dependent
Thalassemia major (Cooley’s) 4 Transfusion dependent
JENNIE LIZA OCAMPO HEMATOLOGY: RBC
• MACROCYTIC ANEMIA
Megaloblastic Non-megaloblastic
DNA metabolism Defective Normal
MCV ­ (100-150 fL) ­ (100-120 fL)
Pancytopenia + -
Macroovalocytes + -
Hypersegmented
+ -
neutrophils

® MEGALOBLASTIC ANEMIA
Lab test Vit B12 deficiency Folic acid deficiency
Serum methylmalonic
­ ­
acid
Schilling’s test + -
Auto-Ab to parietal cells
+ -
(intrinsic factor)
Gastric analysis Achlorhydria (absent) Euchlorhydria (normal)

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 ETIOLOGIC CLASSIFICATION OF ANEMIA ACCORDING TO BM FAILURE

BM FAILURE

ANEMIA OF CONGENITAL
MYELOPHTHISIC PURE RED CELL
APLASTIC ANEMIA CHRONIC KIDNEY DYSERYTHROPOIETIC
ANEMIA APLASIA DISEASE ANEMIA (CDA)

Acquire AA Inherited AA Acquired PRCA Congenital PRCA CDA I

Transient
Diamond Blackfan CDA II / HEMPAS
Idiopathic (70%) Fanconi anemia Erythroblastopenia
anemia (most common)
of Childhood

Secondary Dyskeratosis CDA III (least

(10-15%) congenita common)

Swachman
Bodian-Diamond
Syndrome

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 ANEMIA CAUSED BY RBC DESTRUCTION
Intrinsic Extrinsic (Immune) Extrinsic (Non-immune)
Microangiopathic hemolytic Autoimmune hemolytic
Hereditary spherocytosis
anemia (MAHA) anemia (AIHA)
Traumatic cardiac hemolytic
Hereditary elliptocytosis Alloimune hemolytic anemia
anemia
Exercise-induced Drug-induced immune
Hereditary ovalycytosis
hemoglobinuria hemolytic anemia
Hemolytic anemia caused by
Hereditary stomatocytosis
infectious agents
Hemolytic anemia caused by
Neuroacanthocytosis
RBC injuries
Paroxysmal cold
hemoglobinuria
G6PD deficiency

PK deficiency

JENNIE LIZA OCAMPO HEMATOLOGY: RBC

 HEMOGLOBINOPATHIES
Replacement AA AA replaced Chain
Hb S Valine Glutamic acid 6th position, beta chain
Hb C Lysine Glutamic acid 6th position, beta chain
Hb E Lysine Glutamic acid 26th position, beta chain
Hb O-Arab Lysine Glutamic acid 121st position, beta chain
Hb D Glycine Glutamic acid 121st position, beta chain
Alpha, beta, or gamma
Hb M Tyrosine Histidine
chain
Hb G Lysine Asparagine 68th position, alpha chain

JENNIE LIZA OCAMPO HEMATOLOGY: RBC