Transcript Bleeding cases

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Leucocytes
Kathleen Tennant
Clinical Lead, Diagnostic Laboratories
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Langford Veterinary Services Ltd is a wholly owned subsidiary of the University of Bristol
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Langford Veterinary Services Ltd is a wholly owned subsidiary of the University of Bristol
Leucocyte measurement
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Langford Veterinary Services Ltd is a wholly owned subsidiary of the University of Bristol
Leucocyte measurement
• Most methods use a mixture of impedence
properties and optical scatter/ granularity
to derive total numbers and a differential
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• Fluorescence can give another way of
differentiating cell types
• Information from the graphs can help you
to understand how it has derived the
differential….
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What cell type will the blue ones be?
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What cell type?
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Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
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Lymphocyte
• Lymphocytes are
small compared to the
other leucocytes and
have round, noncomplex nuclei
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On this scatter plot
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Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils are white
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• Knowing what the cells
look like, you can predict
their position and see
how cleanly the colours
are grouped together
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Other measures such as granularity and
lobularity allow a 5 part differential
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What leucocyte type will the green
dots be?
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Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
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Langford Veterinary Services Ltd is a wholly owned subsidiary of the University of Bristol
What leucocyte type will the green
dots be?
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Neutrophils
Lymphocytes
Monocytes
Eosinophils!
Basophils are white
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Eosinnophils
• In dogs and cats the
most obviously
granular nucleated
cells will be
eosinophils
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Leucocytes - Neutrophils
• Combination of absolute
numbers and morphology
changes give the best
chance of correctly
interpreting.
• Mature neutrophils in
three pools – in
circulation, marginated
and mature pool in the
bone marrow
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Mature neutrophilia
• By redistribution (marrow to
blood stream, marginated to
free flowing) in response to
inflammatory mediators or
increased blood pressure
• Decreased loss to tissues in
response to corticosteroids
often with
hypersegmentation
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Left shift
• Once the mature pool has been stripped from
the marrow, if demand outstrips new
neutrophil production, earlier precursors
released:
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• Bands, metamyelocytes, myelocytes
• (Unusual for promyelocytes/ blasts to be
seen in peripheral blood)
• Presence indicates an acute inflammatory
response that is overwhelming the ability of
the marrow to cope
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Case 6: 3 y.o. Working Labrador with pyothorax –
peripheral blood – what is this cell?
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What is this cell?
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Lymphocyte, reactive
Monocyte
Band neutrophil
Metamyelocyte
Myelocyte
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Left shifted neutrophil line
• The white arrow
shows a myelocyte –
reniform, and the
earliest in the
neutrophil maturation
pool
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‘Toxic change’
• In response to overwhelming demand,
dysmature neutrophils released
• Organelles normally removed before the
neutrophil is releasedvpersist, other
organelles not fully matured
• Cytoplasmic basophilia, doehle bodies,
vacuolation, persistent granules (toxic
granulation), ring form nuclei
• Often seen alongside left shift
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Case 6 :Toxic change and left shift
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Case 6 : Toxic change
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Lasercyte
• As immature
neutrophils contain
more RNA, they occupy
a recognisable area of
the scatter plot in this
technology, but the
severity of the left shift
and toxic change are
best evaluated on the
smear
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Neutropenia
• Breed variations (Greyhounds/ sight hounds)
and individual variation: if mild, track.
• May be secondary to decreased production
with marrow disease/ vsuppression (esp
chemo), increased utilisation with marked
inflammation or immune mediated destruction
• With complete marrow destruction or
suppression, neutrophils are the first cell line
to decrease.
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Name the cell
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Name the cell
• Neutrophil
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• Band neutrophil with
toxic change
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• Lymphocyte
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• Monocyte
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Monocytes
• Have marginated and
circulating pools
• Leave circulation to
tissues, differentiate into
macrophages with
inflammatory cytokines.
• Larger than neutrophils,
with a more open nuclear
chromatin
• Cytoplasm blue – grey
and may be vacolated
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Monocytosis
• Steroids may move them out of the
marginated pool
• Many infectious causes: bacterial, fungal,
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protozoal
• Immune mediated disease, sepsis, necrosis,
trauma
• ? systemic studies on prevalence of
diagnostic categories with monocytosis as a
finding – tend to be case reports/ case series
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Lymphocytes
• Small, normal
lymphocytes in
circulation are 1 – 1.5
x red cell size with a
thin rim of cytoplasm
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Lymphocytes on the blood smear
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Reactive lymphocytes
Slightly larger
More basophilic
May have a pale
perinuclear zone
- Seen more frequently in
young animals
- May not reflect function
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Lymphoblasts
• Large lymphoid
cells, larger than
neutrophils
• Their presence in
circulation is
always abnormal
• Look for nucleoli
• Generally
lymphoma/
leukaemia in high
number
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Lymphocytosis
• Lymphocytosis in physiological response as
well as immune stimulation with few diseases
(Ehrlichia, Leishmania, Toxoplasma)
• Addison’s (5 – 10%) of
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• NOT found as a response to vaccination in
various studies (summarised in Avery and
Avery (2007) Vet Clin Small Anim 37 p267 –
282)
• Marked lymphocytosis (> 20 x 10^9/L) raises
concerns for neoplasia
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Lymphopenia
• Lymphopaenia is a
common finding
• Stressed and
diseased animals
• Post steroids and
some
chemotherapeutics
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5 y.o. WHWT with cough and skin
diease. Name that cell
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Name that cell
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Basophil
Toxic neutrophil
Eosinophil
Macrophage
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Eosinophils - eosinophilia
• Commonest causes in dogs – pulmonary
infiltrate with eosinophils and GI disease
(eosinophilic I.B.D.)
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(Lilliehook and Tvedten, Vet
Clin North Am Small
Anim Pract. 2003 Nov; 33 (6):1359-78
• Eosinophilic leukaemias and paraneoplastic
increases also reported
• Hypereosinophilic syndrome (huskies) can give
marked elevations of well differentiated cells
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Eosinophils - eosinopenia
• Usually corticosteroid
related (endogenous or
exogenous)
• Insulin administration
• Diurnal variation in
humans may be reflected
in dogs (fewer in the
morning)
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Coughing 2 y.o. Springer Spaniel.
Name that cell
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Name that cell
• Basophil
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• Toxic neutrophil 2.
• Neutrophil containing
Ehrlichia
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• Eosinophil
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• Macrophage
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Basophils
• In hypersensitivity, parasitic
and paraneoplastic
responses
• Basophilic leukaemias
reported but rare
• Increases in some
myelodyplastic syndromes
• Dirofilaria in imported
• Decreases generally
unrecognised
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Sample number 3235
• 12 y ME Bulldog
• Lethargy, inappetance, mild
lymphadenomegaly, vsplenomegaly
• Biochemistry unremarkable
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Leucocytes through the machine
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WBC
50.30
X 10^9/l
5.50 – 17.00
Neutrophils
10.56
X 10^9/l
3.00 – 11.50
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Lymphocytes 37.73
X 10^9/l
0.70 – 3.60
Monocytes
2.01
X 10^9/l
0.10 – 1.50
Eosinophils
0.00
X 10^9/l
0.20 – 1.40
Basophils
0.00
X 10^9/l
0.00 – 0.10
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Which is the most likely pathology?
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Immune stimulation
Chronic lymphocytic leukaemia
Acute lymphoblasticvleukaemia
Stage 5 lymphoma
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Marked lymphocytosis – with other
leucocytes unaffected
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WBC
50.30
X 10^9/l
5.50 – 17.00
Neutrophils
10.56
X 10^9/l
3.00 – 11.50
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Lymphocytes 37.73
X 10^9/l
0.70 – 3.60
Monocytes
2.01
X 10^9/l
0.10 – 1.50
Eosinophils
0.00
X 10^9/l
0.20 – 1.40
Basophils
0.00
X 10^9/l
0.00 – 0.10
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Langford Veterinary Services Ltd is a wholly owned subsidiary of the University of Bristol
Lymphocytosis
• Cats can have lymphocytosis up to low
twenties with immune stimulation
• Can not tell whether leukaemia or stage 5
lymphoma based on smear
or bone marrow –
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needs clinical assessment and observation of
progression
• Morphology on the smear needed to tell if
acute (poorly differentiated/ large lymphoid
cells) or chronic lymphocytic (small/ well
differentiated)
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Large granular lymphocytes in very high numbers –
suspicious for large granular lymphocyte leukaemia
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Large granular lymphoid leukaemia
can start in spleen as well as marrow
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• These lymphocytes can
be seen in health and
in reactive processes,
but not normally in
these numbers
• High numbers of Howell
– Jolly bodies (arrowed)
– seen in red cell
regeneration (not here!)
and in some animals
with splenic disease
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