Color Atlas of Hematology - Practical and Clinical Diagnosis

209 Pages·2004·5.349 MB·English

by  Harald Theml, Heinz Diem, Torsten Haferlach

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ii
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ColorAtlasofHematology
PracticalMicroscopicandClinicalDiagnosis
HaraldTheml,M.D.
Professor,PrivatePractice
Hematology/Oncology
Munich,Germany
HeinzDiem,M.D.
KlinikumGrosshadern
InstituteofClinicalChemistry
Munich,Germany
TorstenHaferlach,M.D.
Professor,KlinikumGrosshadern
LaboratoryforLeukemiaDiagnostics
Munich,Germany
2ndrevisededition
262colorillustrations
32tables
Thieme
Stuttgart·NewYork
iv
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v
Preface
OurCurrentEdition
AlthoughthisisthesecondEnglisheditionofourhematologyatlas,this
editioniscompletelynew.Asanimmediatesignofthischange,thereare
nowthreeauthors.Thecompletelyupdatedvisualpresentationusesdig-
italimages,andthecontentisorganizedaccordingtothemostup-to-date
morphologicalclassificationcriteria.
Inthisnewedition,ournewlyformedteamofauthorsfromMunich
(the“MunichGroup”)hassuccessfullysharedtheirknowledgewithyou.
HeinzDiemandTorstenHaferlacharenationallyrecognizedaslecturers
ofthediagnosticscurriculumoftheGermanAssociationforHematology
andOncology.
Goals
Mostphysiciansarefundamentally“visuallyoriented.”Apartfromimme-
diatepatientcare,themicroscopicanalysisofbloodplaystothisprefer-
ence. This explains the delight and level of involvement on the part of
practitionersinthepursuitofmorphologicalanalyses.
Specialization notwithstanding, the hematologist wants to preserve
theopportunitytoperformgroundbreakingdiagnosticsinhematologyfor
thegeneralpractitioner,surgeon,pediatrician,theMTAtechnician,andall
medical support personnel. New colleagues must also be won to the
cause. Utmost attention to the analysis of hematological changes is es-
sentialforatimelydiagnosis.
Even before bone marrow cytology, cytochemistry, or immunocyto-
chemistry,informationbasedontheanalysisofbloodisofimmediaterel-
evanceinthedoctor’soffice.Itiscentraltothediagnosisofthediseasesof
the blood cell systems themselves, which make their presence known
throughchangesinbloodcomponents.
Theexhaustivequantitativeandqualitativeuseofhematologicaldiag-
nostics is crucial. Discussions with colleagues from all specialties and
teachingexperiencewithadvancedmedicalstudentsconfirmitsimpor-
tance.Incaseswhereadiagnosisremainselusive,theawarenessofthe
next diagnostic step becomes relevant. Then, further investigation
throughbonemarrow,lymphnode,ororgantissuecytologycanyieldfirm
results.Thispocketatlasoffersthebasicknowledgefortheuseofthese
techniquesaswell.
vi Preface
Organization
Reflectingourgoals,theinductiveorganizationproceedsfromsimpleto
specializeddiagnostics.Bydesign,wesubordinatedthedescriptionofthe
bonemarrowcytologytothediagnosticbloodanalysis(CBC).However,
wehaverespondedtofeedbackfromreadersofthepreviouseditionsand
have included the principles of bone marrow diagnostics and non-
ambiguousclinicalbonemarrowfindingssothatfrequentandrelevant
diagnosescanbequicklymade,understood,orreplicated.
Thenosologyanddifferentialdiagnosisofhematologicaldiseasesare
presentedtoyouinatabularform.Wewantedtoofferyouapocketbook
foreverydaywork,notareferencebook.Therefore,morphologicalcuri-
osities,oranomalies,areabsentinfavorofapracticalapproachtomor-
phology. The cellular components of organ biopsies and exudates are
brieflydiscussed,mostlyasareminderoftheimportanceofthesetests.
Theimagesareconsistentlyphotographedastheynormallyappearin
microscopy (magnification 100 or 63 with oil immersion lens, oc-
casionallymaster-detailmagnificationobjective10or20).Eventhough
surprisingperspectivessometimesresultfromviewingcellsatahigher
magnification,thedownsideisthatthisbynomeansfacilitatestherecog-
nitionofcellsusingyourownmicroscope.
InstructionsfortheUseofthisAtlas
Theorganizationofthisatlassupportsasystematicapproachtothestudy
ofhematology(seeTableofContents).Theindexofferswaystoanswer
detailedquestionsandaccessthehematologicalterminologywithrefer-
encestothemaindescriptionandfurthercitations.
Thebestwaytobecomefamiliarwithyourpocketatlasistofirsthavea
cursorylookthroughitsentirecontent.Theimagesareaccompaniedby
shortlegends.Onthepagesoppositetheimagesyouwillfindcorrespond-
ingshortdescriptivetextsandtables.Thistextportiondescribescellphe-
nomenaanddiscussesinmoredetailfurtherdiagnosticstepsaswellas
thediagnosticapproachtodiseasemanifestations.
Acknowledgments
Twentyyearsago,ProfessorHerbertBegemanndedicatedtheforewordto
thefirsteditionofthishematologyatlas.Heacknowledgedthat—beyond
cellmorphology—thisatlasaimsattheclinicalpictureofpatients.Weare
gratefulforbeingabletocontinuethistradition,andfortheimpulsesfrom
ourteachersandcompanionsthatmakethispossible.
Wethankourcolleagues:J.Rastetter,W.Kaboth,K.Lennert,H.Löffler,
H.Heimpel,P.M.Reisert,H.Brücher,W.Enne,T.Binder,H.D.Schick,W.
Hiddemann,D.Seidel.
Munich,January2004 HaraldTheml,HeinzDiem,TorstenHaferlach
vii
Contents
PhysiologyandPathophysiologyofBloodCells:
MethodsandTestProcedures ............................ 1
IntroductiontothePhysiologyandPathophysiologyofthe
HematopoieticSystem ....................................... 2
CellSystems .................................................. 2
PrinciplesofRegulationandDysregulationintheBloodCell
SeriesandtheirDiagnosticImplications ........................ 7
Procedures,Assays,andNormalValues ....................... 9
TakingBloodSamples ......................................... 9
ErythrocyteCount ............................................ 10
HemoglobinandHematocritAssay ............................. 10
CalculationofErythrocyteParameters .......................... 10
RedCellDistributionWidth(RDW) ............................ 11
ReticulocyteCount ............................................ 11
LeukocyteCount .............................................. 14
ThrombocyteCount .......................................... 15
QuantitativeNormalValuesandDistributionofCellularBlood
Components ................................................. 15
TheBloodSmearandItsInterpretation(DifferentialBloodCount,
DBC) ......................................................... 17
SignificanceoftheAutomatedBloodCount ..................... 19
BoneMarrowBiopsy .......................................... 20
LymphNodeBiopsyandTumorBiopsy ......................... 23
Step-by-StepDiagnosticSequence ............................ 25
NormalCellsoftheBloodandHematopoieticOrgans . 29
TheIndividualCellsofHematopoiesis ........................ 30
ImmatureRedCellPrecursors:ProerythroblastsandBasophilic
Erythroblasts ................................................. 30
MatureRedBloodPrecursorCells:PolychromaticandOrtho-
chromaticErythroblasts(Normoblasts)andReticulocytes ....... 32
ImmatureWhiteCellPrecursors:MyeloblastsandPromyelo-
cytes ........................................................ 34
viii Contents
PartlyMatureWhiteCellPrecursors:MyelocytesandMetamyelo-
cytes ........................................................ 36
MatureNeutrophils:BandCellsandSegmentedNeutrophils ..... 38
CellDegradation,SpecialGranulations,andNuclearAppendages
inNeutrophilicGranulocytesandNuclearAnomalies ............ 40
EosinophilicGranulocytes(Eosinophils) ........................ 44
BasophilicGranulocytes(Basophils) ............................ 44
Monocytes ................................................... 46
Lymphocytes(andPlasmaCells) ............................... 48
MegakaryocytesandThrombocytes ............................ 50
BoneMarrow:CellCompositionandPrinciplesofAnalysis .... 52
BoneMarrow:MedullaryStromaCells ......................... 58
AbnormalitiesoftheWhiteCellSeries .................. 61
PredominanceofMononuclearRoundtoOvalCells ........... 63
ReactiveLymphocytosis ...................................... 66
ExamplesofExtremeLymphocyticStimulation:Infectious
Mononucleosis ............................................ 68
DiseasesoftheLymphaticSystem(Non-HodgkinLymphomas) ... 70
DifferentiationoftheLymphaticCellsandCellSurfaceMarker
ExpressioninNon-HodgkinLymphomaCells ................. 72
ChronicLymphocyticLeukemia(CLL)andRelatedDiseases .... 74
LymphoplasmacyticLymphoma ............................. 78
FacultativeLeukemicLymphomas(e.g.,MantleCellLymphoma
andFollicularLymphoma) ................................... 78
Lymphoma,UsuallywithSplenomegaly(e.g.,HairyCellLeuke-
miaandSplenicLymphomawithVillousLymphocytes) ....... 80
MonoclonalGammopathy(Hypergammaglobulinemia),Mul-
tipleMyeloma*,PlasmaCellMyeloma,Plasmacytoma ......... 82
VariabilityofPlasmacytomaMorphology ..................... 84
RelativeLymphocytosisAssociatedwithGranulocytopenia
(Neutropenia)andAgranulocytosis ............................ 86
ClassificationofNeutropeniasandAgranulocytoses ........... 86
Monocytosis ................................................. 88
AcuteLeukemias ............................................. 90
MorphologicalandCytochemicalCellIdentification ........... 91
AcuteMyeloidLeukemias(AML) ............................. 95
AcuteErythroleukemia(FABClassificationTypeM ) .......... 100
6
AcuteMegakaryoblasticLeukemia
(FABClassificationTypeM ) ................................. 102
7
AMLwithDysplasia ........................................ 102
HypoplasticAML ........................................... 102
Contents ix
AcuteLymphoblasticLeukemia(ALL) ........................ 104
Myelodysplasia(MDS) ...................................... 106
PrevalenceofPolynuclear(Segmented)Cells ................. 110
NeutrophiliawithoutLeftShift ................................ 110
ReactiveLeftShift ............................................ 112
ChronicMyeloidLeukemiaandMyeloproliferativeSyndrome
(ChronicMyeloproliferativeDisorders,CMPD) .................. 114
StepsintheDiagnosisofChronicMyeloidLeukemia .......... 116
BlastCrisisinChronicMyeloidLeukemia ..................... 120
Osteomyelosclerosis .......................................... 122
ElevatedEosinophilandBasophilCounts ....................... 124
ErythrocyteandThrombocyteAbnormalities ........... 127
ClinicallyRelevantClassificationPrincipleforAnemias:Mean
ErythrocyteHemoglobinContent(MCH) ....................... 128
HypochromicAnemias ....................................... 128
IronDeficiencyAnemia ....................................... 128
HypochromicInfectiousorToxicAnemia(SecondaryAnemia) ... 134
BoneMarrowCytologyintheDiagnosisofHypochromicAne-
mias ....................................................... 136
HypochromicSideroachresticAnemias(SometimesNormo-
chromicorHyperchromic) .................................... 137
HypochromicAnemiawithHemolysis ......................... 138
Thalassemias ............................................... 138
NormochromicAnemias ..................................... 140
NormochromicHemolyticAnemias ............................ 140
HemolyticAnemiaswithErythrocyteAnomalies ................ 144
NormochromicRenalAnemia(SometimesHypochromicor
Hyperchromic) ............................................... 146
BoneMarrowAplasia ......................................... 146
PureRedCellAplasia(PRCA,Erythroblastopenia) ............. 146
AplasiasofAllBoneMarrowSeries(Panmyelopathy,Pan-
myelophthisis,AplasticAnemia) ............................. 148
BoneMarrowCarcinosisandOtherSpace-OccupyingProcesses .. 150
HyperchromicAnemias ...................................... 152
ErythrocyteInclusions ....................................... 156
HematologicalDiagnosisofMalaria ............................ 158