LEUCOCYTIC DISORDERS

Group : 958 – 968

Supervised by :
DR. DALIA NAFEA
AGENDA
o INTRODUCTION
o LEUKOPENIA
I) HEREDITARY LEUKOPENIA
II) ACQUIRED LEUKOPENIA
o LEUKOCYTOSIS
I) GRANULOCYTOSIS
II) MONOCYTOSIS
III) LYMPHOCYTOSIS
 INTRODUCTION
Mohamed samir mohamed elsaid (958)
WBCs: “Leucocytes”
Are cells of the immune systems involved
in defending the body against both infectious
disease and foreign materials.
 Types:
WBCs T -lymphocytes B -lymphocytes

Granulocytes A granulocytes

Neutrophils Eosinophils Basophils Monocytes Lymphocytes

Genesis:
1=myeloblast. 7=polymorphnuclear neutrophil. (13-16)=stages of monocyte
2=promyelocyte. 8=eosinophil myelocyte. formation.
3=megakaryocyte. 9 = eosinophil metamyelocyte.
4=neutrophil myelocyte 10= polymorphonuclear eosinophil.
5=metamyelocyte. 11=basophil myelocyte.
6="band" metamyelocyte 12= polymorphonuclear basophil.
I. NEUTROPHILS
They have a distinctive multilobed nucleus (hence the name
polymorph) and neutral staining granules.

Normal value: (2.5 – 7.5 x 109 /L)

:Function
ingest & kill bacteria, fungi and damaged cells, either directly
or by (opsonization) to make them more ingestible as
neutrophils have Fc and C3b receptors
 II.EOSINOPHILS
They are slightly larger than neutrophils and are
characterized by a nucleus with usually 2 lobes and large
cytoplasmic granules that stain deeply red.
Normal value: (O.O4 –O.4 x109 /L)
:Function
The main role is protection against multicellular parasites
such as worms (helminthes). This is achieved by the release of
:.toxic, cationic proteins e.g
Major basic protein (MBP).  Eosinophil cationic protein
.(ECP)
Eosinophil neurotoxin.  Eosinophil peroxidase
 III.BASOPHILS
 The nucleus of basophils is similar to that of
neutrophils but the cytoplasm is filled with large black
.granules
The granules contain histamine, heparin, and
.enzymes such as myeloperoxidase
 Normal value:( o.o1 – o.1 x109 /L)
Function:(Unknown)
Binding of IgE causes the cells to degranulate and
release histamine and other contents involved in acute
hypersensitivity reactions
 IV.MONOCYTES
.They are slightly larger than neutrophils
The nucleus has a variable shape and
may be round, indented or lobulated. The cytoplasm
.contains few granules than neutrophils
Normal value: (o.2 – o.8 x 10 9 /L)
:Function
precursors of tissue macrophages and dendritic cells
V.LYMPHOCYTES
They are small cell, a little larger
.than RBCs, with a dark-staining central nucleus
There are 2 main types: T and B lymphocytes
 Normal value: (1.5 – 3.5 x 109/L)
 Function:
The T cells mediate cellular immunity
The B cells mediate humoral immunity
Hereditary Leukopenia
Mohamed salama alradi ahmed (959)
LEUKOPENIA
Definition
A reduction in the total numbers of circulating white cells,
this may be due to a reduction in all types of white cells or
individual cell types.

Leucopenia may occur in isolation or as apart of pancytopenia.

In general, an ANC of

- 1000-1500/μL indicates mild neutropenia
- 500-1000/μL  indicates moderate neutropenia
- less than 500/μL indicates severe neutropenia.
Classification
I) Hereditary
II) Acquired
Hereditary Leukopenia
Causes
Infantile Genetic Agranulocytosis (kostamann Syndrome)

Familial Chronic Benign Neutropenia

Congenital Aleukia or Reticular Dysgenesis

Isoimmune Neonatal Neutropenia

Periodic or Cyclic Neutroprnia (Cyclical Haematopoiesis)

KOSTAMANN SYNDROME
Background
 It is inherited as an autosomal recessive disease.
The absolute neutrophil count (ANC) is characteristically
less than 200/μL. Severe persistent neutropenia results in
an increased susceptibility to frequent bacterial infections.
Consanguinity of the parents was reported.
Incidence
Neutropenia occurs in 1-2 cases per million population.
Mortality/Morbidity
The mortality rate is 70% within the first year of life in the
absence of medical intervention with granulocyte colony-
stimulating factor (G-CSF), bone marrow transplantation,
or peripheral blood stem cell transplantation.
KOSTAMANN SYNDROME
Pathophysiology
Mutations in the gene (ELA2) encoding neutrophil elastase
appear to be present in most patients. These mutations may be
responsible for the untimely initiation of apoptosis in
myelocytes, producing their premature destruction, and
interrupting the normal cycle of maturation.
Race
Most of the initial patients reported by Kostmann were seen in in
northern Sweden.
Sex
Incidence is equal in males and females.
Age
Classic Kostmann disease is recognized in early infancy.
 KOSTAMANN SYNDROME
Clinical
 History
 Symptoms of Kostmann disease include the following:
-Temperature instability in newborn period
- Fever
- Irritability
- Localized site(s) of infection
 Physical
 Signs and symptoms of Kostmann disease include :
- Oral ulcers, Gingivitis.
- Pharyngitis, Sinusitis, otitis media
- Lymphadenopathy, lymphadenitis
- Bronchitis, pneumonia
- Splenomegaly
- Neurological symptoms, including epilepsy and neuropsychological deficits
 KOSTAMANN SYNDROME
Laboratory Studies
With regard to CBC count with differential:
- An absolute neutrophil count (ANC) less than 200/μL is seen in classic cases.
Monocytosis and eosinophilia may be evident.
- Total leukocyte counts are frequently normal because of the monocytosis.
- Mild anemia may be present from chronic inflammation, and thrombocytosis
may be present.

Quantitative immunoglobulins may show hypergammaglobulinemia. Patients have a

normal response to vaccinations.

Complement levels are typically normal.

 Antineutrophil antibodies are absent but should be checked to exclude an autoimmune

etiology.

Electrolyte levels and renal and liver function test results are within the reference range.
 KOSTAMANN SYNDROME
Normal neutrophils transfusion in the affected patients left the
blood at approximately normal rates, suggesting that the defect
is in cell production rather than in increased cell destruction.
The transfer of normal plasma did not alleviate the
neutropenia or alter the appearance of the bone marrow.
Bone marrow aspiration or biopsy
Reveals an arrest of neutrophil precursor maturation at the
promyelocyte or myelocyte level. Cytogenetic analysis typically
reveals a normal bone marrow karyotype.
Vacuoles and atypical nuclear shapes are prominent in the
promyelocyte and myelocyte and atypical erythroid forms also
have been noted.
KOSTAMANN SYNDROME
Treatment
Bone marrow transplantation
Because normal neutrophils differentiation has been
induced by addition of conditioned medium (CSF) to
cultures of patient´s marrow.
Colony-stimulating factors(Filgrastim)
These agents are used to stimulate neutrophil production
and act as hematopoietic growth factors that stimulate the
development of granulocytes. They are used to treat or
prevent neutropenia.
In patients treated with rhG-CSF, the blood neutrophils
concentration increased to greater than 1000/μL.
CYCLIC NEUTROPENIA
It is inherited as an autosomal dominant trait.
It is congenital in 75 % of patients.
It is characterized by recurrence of malaise, fever, mild
infection, cervical lymphadenopathy and the
association of these symptoms with neutropenia is
well established.
Episodes recur at approximately 3- weeks intervals and
symptomatic periods may last free or four to ten days.
The course of the disorder in affected individual is
marked by recurrent infections with periods of well-
being interspersed.
CYCLIC NEUTROPENIA
Blood picture
During the symptomatic period, the blood neutrophil
concentration is reduced, and lymphocytosis,
monocytosis, and/or eosinophilia has been noted in
some patients.
Thrombocytopenia has been reported in a few
patients.
Between attacks, the symptoms disappear completely,
and the neutrophil count returns to nearly normal
levels.
CYCLIC NEUTROPENIA
Examination of the B.M. demonstrated that granulocyte
precursors disappear prior to the onset of neutropenia and
reappear before neutrophils reappear in the blood.
The findings suggest that the disorder results from a periodic
failure of blood cell production, most likely at the
pleuripotent stem cell level.
This hypothesis has been supported further by
(1) Failure to find leukoagglutinins in the serum.
(2) Inability to inhibit in vitro neutrophil migration or
phagocytic capacity by relapse phase serum.
(3) Failure to produce neutropenia or clinical manifestations in
persons transfused with patient's serum.
CYCLIC NEUTROPENIA
Treatment
Antibiotics
decrease the severity of bacterial infections and reduce
the likelihood of dissemination and death.
Splenoectomy
repoted to result in fewer symptoms in older patients
and in those with splenomegaly although not
eliminating the cycling.
Adrenal corticosteroids and androgenic hormones
reported to eliminate the cell cycling in blood and bone
marrow especially in adult patients.
CYCLIC NEUTROPENIA
Treatment
Recombinant human CSF
Daily IV and SC injection of rhG-CSF was shown :
(1) to increase the mean neutrophil from about 700 cell /µl to
9800 cells/µl.
(2) to reduce the duration of severe neutropenia (<200 cells/µl)
from about 12.7 to 0.7 days /month.
(3) although cycling persisted in all but one patients, the
duration of the cycle was reduced from 21 to 14 days. In addition,
treatment with G-CSF reduced the severity and number of
clinical manifestations dramatically with minimal side effects.
ACQUIRED LEUKOPENIA
MOHAMED SABER ABOHASSEN (965)
Acquired leukopenia
I- Causes & pathogenesis

II- Investigations

III- Treatment
I - CAUSES
A- Infectious causes

VIRAL BACTERIAL PROTOZOAL

CMV & EBV

TUBERCULOSIS BRUCELLOSIS BILHARZIA MALARIA

B- Haematological
1-Megaloblastic anaemia
(folic acid ,vitB12 deficiency)
2-Bone marrow failure
a- Aplastic anaemia
b- myelofibrosis
c- myelodysplasia
d- neoplasm
(leukemia,lymphoma,secondries)
C - Anaphylactic shock

D - Immune mediated:
a- Systemic Lupus Erythamatous
b-Felty syndrome
c-HCV
d-Autoimmune neonatal neutropenia

E - drugs
II. INVESTIGATIONS
A-laboratory investigations
1- CBC
2-Folate & VitB12 serum level
3-ANCA&ANTIDNA
4-Serology (if suspect infection)
(e.g Widal test)
B - Radiology

1-X_RAY

2-ULTRASOUND

3-CT
C-Interventional

1- Culture(if suspect infection)

2-Bone Marrow Aspiration

3- Trephine Bone Marrow Biopsy

(in cases of pancytopenia
to avoid dry tab)
 III. TREATMENT
1- IF hypersplenism splenctomy
2-IF drugs stop it
3-vitB12 &folate deficiency
( give parenteral vitB12 or oral folate)
4- Immune:
a-high dose of corticosteroid
b- splenectomy
c - anticd20(ratixumab)
5-Infection(give suitable antibiotic or antiviral or
anti parasitic)
6- IF anaphylactic shock make appropriate management
 LEUKOCYTOSIS
MOHAMED SEIF ELNASER (961)
 Definition
Elevation of WBC count above the mean value of
circulating white cells.

The usual explanation for

leukocytosis is neutrophilia.

leukocytosis is considered when

total WBC count exceeds 11000/mm³.
 
 Classification
1. Granulocytosis:
Neutrophilia
Eosinophilia
Basophilia
2. Monocytosis
3. Lymphocytosis
 Granulocytosis
Neutrophilia
Elevation of the absolute neutrophil
count "ANC" which is calculated by
ANC= (%band + %mature) × WBC
Neutrophilia :when neutrophilic count
exceeds 7,500/mm³.
Mechanisms
1. Increased production.
2. Accelerated/early release from marrow→blood.
3. Demargination (marginal pool→circulating pool)
 Classification
Primary causes
Hereditary neutrophilia
Chronic idiopathic
neutrophilia
AML and CML
Familial myeloproliferative
disease
Congenital anomalies
Leukocyte adhesion factor
deficiency (LAD)
Familial cold urticaria
Secondary causes
Acute infection
Inflammation
e.g. rhematoid arthritis
Stress neutrophilia
Drug induced
Non-hematologic malignancy
Generalized marrow
stimulation as in hemolysis
Asplenia and hyposplenism
Primary causes of neutrophilia
1. Hereditary neutrophilia
Usually associated with splenomegally and widened diploe of
the skull.
The defect seemed to be dominatly inherited.
The LAP score are usually high. The neutrophil function and
CD18/CD11b expression in the affected individuals are normal

2. Chronic idiopathic neutrophilia

Chronic leukocytosis occurring in patients who are otherwise
well. Bone marrow aspirations, LAP scores are normal.
Normal subjects fall outside of the 95th percentile with
respect to WBC.
A diagnosis of exclusion
3. AML and CML will be discussed in details later on.
4. Familial myeloproliferative disease
MPD with monosomy 7 may have familial features
All of the affected subjects had low LAP scores.
JAK2 mutations
5. Congenital anomalies and leukemoid reaction
e.g. Tetralogy of fallot and down syndrome.
6. Leukocyte adhesion factor deficiency"LAD"
The diagnosis is established by
demonstration of marked reduction or absence in the
CR3 receptor(CD11b/CD18) on granulocytes.
7. Familial cold urticaria and leukocytosis
The skin rash in these patients is characterized
histologically by a marked infiltration by neutrophils.
 Secondary causes of neutrophilia
1. Acute infection
The most common cause of leukocytosis.
Modest (uncommonly >30 × 10⁹/L),
associated with a left shift and
toxic granulations
Certain bacteria such as
pneumococcus or staphylococcus
may cause particularly high leukocyte counts.
2. Acute and chronic inflammation
e.g. trauma, infarction, vasculitis, rheumatoid arthritis,
burns…..
It is due to release of cytokines by inflammatory cells
3. Stress neutrophilia
Within minutes of exercise , stress or epinephrine
injections caused by movement of neutrophils from the
marginated pool into the circulatory pool.
Pretreatment with propranolol can block
neutrophilia.
Post-operative period, there is doubling
of leukocyte count approximately 3 hours
after surgery.
Interesting association between
leukocyte count and MI??
4. Drug induced
Steroids through inducing release of neutrophils from
bone marrow.
Leukocytosis as high as 200,000/mm³ in neonates has
been associated with maternal steroid administration.
β agonists through releasing neutrophils
from marginated pool
also anticonvulsants e.g. phenytoin.
Lithium through production of "CSF"
and has been used for treatment of neutropenia.
Other drugs include tetracycline and granulocyte CSF
5. Non-hematologic malignancy
Tumors from lung "frequently large cell lung
cancer", stomach, breast and neuroblastoma in
children through irritation of WBC precursors.
Solid tumors of tongue, lung and kidney
produce CSF "paraneoplasic syndrome".

6. Marrow stimulation
As in hemolytic anemia, immune thrombocytopenia.
e.g. sickle cell anemia (2 mechanisms?) and ITP
 leukemoid reaction
Definition
a reactive and excessive leucocytosis characterized by
the presence of immature cells (band forms,
metamyelocytes, myelocytes and occasionally
promyelocytes and myeloblasts) in the peripheral
blood.
Causes
i. Acute infections,
ii. Malignant infiltration of the bone marrow ,
iii. Tuberculosis
iv. Others: haemorrhage or haemolysis.
leukemoid reaction
Toxic granules ,vavuoles and Döhle body
 Differences between CML and leukemoid reaction
CML Leukemoid reaction
WBC >50,000 <50,000
Basophilia +ve -ve
NAP score low high
Toxic granulations -ve +ve
Cytogenetics Philadelphia +ve -ve
Splenomegaly Huge splenomegaly No huge
splenomegaly
Effect of antibiotics No rsponse Good response
"usually infectious"
 Leukoerythroblastic response
Definition
Presence of immature RBCs "Nucleated red cells, teardrop-
shaped erythrocytes" and white cell precursors "Promyelocyte and
myelocytes" in the peripheral blood.

Causes
1. Marrow infiltration with metastatic carcinoma,
2. Myelofibrosis,
3. Granulomatous reactions e.g. tuberculosis
4. Others: non-hodgkin lymphoma,myeloma, osteopetrosis, severe
hemolytic or megaloblastic anemia.

 It is due to irritative or inflammatory process in the marrow

itself.
Leukoerythroblastic reaction
 Clinical approach to a case of
neutrophilia
History
History of infection e.g. fever or any other inflammatory conditions
"e.g. rheumatoid arthritis, trauma, burn…",
Symptoms of malignancy e.g. persistent low grade fever and weight
loss
Symptoms of bone marrow infiltration by leukemic cells e.g.
anemia "easy fatigue, dyspnea, palpitation…" and
thrombocytopenia "bleeding".
History of drugs e.g. steroids and history of operations.

Examination
We should examine the patient for signs of infection "e.g.
elevated temperature" or an underlying haematological disorder
"e.g. huge splenomegaly in CML".
 Investigation
WBC count and blood film:
Extremely high leukocytic counts (may >200 ×10⁹/L)
suggest →CML
Modest (uncommonly >30 × 109/L), associated with a
left shift and toxic granulations→acute infection.
Moderate neutrophilia following steroid therapy.
Mild neutrophilia may be induced by stress or exercise.
Blast cells → acute leukemia
Leucoerythroblastic blood film
is due to → bone marrow invasion by tumour, fibrosis
or granuloma formation and is an indication for a bone
marrow biopsy..
NAP score: low in CML, high in leukemoid reaction.
Cytogenetics: Philadelphia chromosome is positive
in more than 95% of cases of CML. Also it is useful to
diagnose familial myeloproliferative disorders.
Cell markers"CDs": absence of the CR3
receptor(CD11b/CD18) on granulocytes occurs in
LAD, but normally expressed in hereditary
neutrophilia.
ESR: highly elevated in malignancy and collagenic
diseases
ACUTE MYELOGENOUS LEUKEMIA
MOHAMED SAID ABOUSHOSHA (960)
INTRODUCTION
Acute myelogenous leukemia (AML) is the final
common pathway of a finite number of mutational
events in hematopoietic marrow-derived stem cells
resulting in increased proliferation, decreased
apoptosis, and failure to differentiate into red cells,
granulocytes, monocytes and platelets.

Marrow failure ensues rapidly, leading to death

(hyperleukocytosis).
Epidemiology
15% to 20% of acute leukemia in children and adolescents and 90%
in adults.
AML is a disease of aging, the median age at diagnosis of AML was
64 years.
Risk Factors
age has a particular impact in incidence of AML cases arising
from prior myelodysplastic syndrome.
Rare cases of congenital diseases associated with chromosome
breakage or defective DNA repair ( e.g. Fanconi's anemia ) are
at increased risk for development of AML.
Children with congenital neutropenia associated with a
mutated granulocyte colony-stimulating factor ( G-CSF)
receptor ( kostmann's syndrome) are also at risk.
 By far the greatest risk for AML, however, is associated with receipt
of cytotoxic therapy
 patients treated for breast cancer, lymphoma, and childhood acute
lymphocytic leukemia. Such AML is called " Secondary " or treatment-
related AML.
 Secondary AML assumes two forms. Alkylating agent-associated
AML occurs within 5-10 and becomes rare thereafter. Topoisomerase
II inhibitor-associated AML occurs with a latency of less than 5 years
and is seen after use of drugs such as anthracyclines and
epipodophyllotoxins.
 Environmental exposures

 Because most patiens given alkylating agents or exposed to benzene do

not develop AML, other factors including genetic predisposition likely
to play a rule.
Pathophysiology
 It is becoming increasingly apparent that AML has a multistep pathogenesis and an
evolving clinical process.

Bone Marrow
Normal blast AML blast

Diff. cells with normal ability diff. cells with reduced ability

Ery. G/M Megakaryocytic Ery. G/M Megakaryocytic

Blood

RBC’s G/M Platelets

Circulating blasts
 Blood
RBCs G/M Platelets Circulating blasts

hyperleucocytosis Organ affection

Infection, Bleeding, Organ failure Organ failure

DEATH
Classification
The FAB classification was developed in 1985 by the " French-
American-British cooperative group" based in particular on
morphological and cytohemical characteristics.
FAB system
AML minimally differentiated (M0)
AML without maturation (M1)
AML with maturation (M2)
Acute promyelocytic leukemia (M3)
Acute myelomonocytic leukemia (M4)
Acute monocytic leukemia (M5)
Acute erythroid leukemia (M6)
Acute megakaryocytic leukemia (M7)
WHO Classification: more recent, take into account additional
molecular and immunphenotypical characteristics.
 
Clinical Picture
Non specific general symptoms usually with brief
medical history: reduced performance status, fever,
night sweats, fatigue, loss of appetie, weight loss, bone
pain and flu-like sumptoms.

Impairment of normal Haematopoiesis

Anemia: weakness, fatigue, tachycardia, pallor of skin
and mucous membranes.
Thrombopenia: increased bleeding tendency, with
petechia and ecchymosis, haematoma, epistaxis.
Granulocytopenia: skin infection, pneumonia, sepsis.
Leukemia cell proliferation, organ infiltration
Hepatosplenomegaly
Chloroma (extramedullar tumorous manifestations)
Cns involvement with headache, nausea/vomiting, visual
impairment, central nervous disturbances.
 
Leukostasis (frequent with leukocytes > 100.000/mgl) :
pulmonary symtoms ( dyspnea, pulmonary leukemic infiltrates),
cerebral stasis ( ischemia, hemorrhage), arterial embolism

Dissemunated intravascular coagulation( DIC), especially in

AML M3 due to the presence of pro-coagulants granules.

Skin infiltrates, gingival hyperplasia, CNS involvement. In

particular with AML M4/M5.
Chloroma gingival hyperplasia
Skin infiltration
 Investigations
Laboratory tests
Complete blood count, differential blood count
Increased white blood cell count with blasts in peripheral blood
Anemia
Granulocytopenia
Thrombocytopenia
No blasts in the peripheral smear is rare (aleukemic leukemia)

Bone marrow examination

Acute leukemias are defined by the presence of >20% blasts in bone marrow.

Routine laboratory tests with liver and renal parameters ( uric acid), electrolytes,
LDH.
Coagulation parameters (DIC)
Microbiological diagnostics if febrile, virus serum titres
HLA typing of patient and all siblings ( search for HLA-identical family donor for
possible matched related allogenic blood stem cell transplantation)
CSF cytology (cerebrospinal fluid ) in selected cases.
Imaging
Chest x-ray, abdominal ultrasound, ECG,
 Echocardiography before anthracycline treatment ( of possible
cardiotoxicity).

Differential diagnosis
1) Myelodysplastic syndrome ( 20% blasts as the minimal diagnostic
criteris for AML, patients below there cutoffs but with excess blasts
(>5%) have myelodysplastic syndrome. However, the decision to
treat a patient as having AML rather than myelodysplastic
syndrome should rest at least as much on the clinical as on the
morphological picture, and may have similar outcome)
2) CML in blast crisis
3) Lymphoblastic leukemia
4) Aplastic anemia
5) Leukemoid reaction
 Treatment
Supportive treatment
 Sperm cryopreservation (prior to induction therapy, if possible)
 Prophylaxis of tumor lysis syndrome: fluid replacement, urine alkalization,
allopurinol, rasburicase.
 Prevention and treatment of infection
 Substitution of red cells and platelet concentrates ( in DIC and/or AML M3
keep platelets>50,000mgl)
 Substitution of coagulation factors, if necessary treatment of DIC.
 In hyperleukocytosis/leukostasis: immediate treatment with hydrooxyurea,
oxygen therapy, fluid substitution, restrictive substitution of red cells, possibly
dexamethasone i.v.emergency leukapheresis may be required.
 Suppression of menstruation in premenopausal females.
Induction treatment
 Objective: reaching complete remission (CR) i.e. normalization of blasr count
in bone marrow (<5%) as well as normal platelet and granulocyte counts
 Using " 7&3": 7-days continous IV infusion of cytaraine at 100 mg/m2/day and
3-day bolus IV infusion of anthracycline.
 CR rates in the 60-80%
Consolidation: further reduction of the malignant
clone by additional chemotherapy cycles after
reaching complete remission

Intensification: according to risk factors,

Allogenic transplantation in first remission ( related or

unrelated donor): with " poor risk" and " intermediate
risk"karyotype.
All other stages: no remission ( refractory leukemia),
relapse
Second CR: allogenic transplantation from related or
unrelated donor.
CHRONIC MYELOID LEUKEMIA
MOHAMED SHERIF AHMED (962)
 Pathophysiology
The genetic hallmark of CML is translocation t(9;22)
(q34;q11) resulting in creation of Philadelphia
chromosome .On the molecular level ,this translocation
fuses sequences of the BCR gene on chromosome 22 with
sequences of ABL gene on chromosome 9. Resulting in
abnormal fusion protein (p210) with increased tyrosine
kinase activity.
In most newly diagnosed patients, the Ph chromosome is
found in almost all cells of granulocytic, erythroid, and
megakaryocytic series. It is present in B lymphocytes and a
small proportion of T lymphocytes but not in marrow fibro
blasts or other tissues.
The PH chromosome is found in about 90% of patients with
clinical manifestations of CML; about 10% of patients have
morphologically normal appearing 9 and 22 chromosome
therefore classified as Ph chromosome-negative CML
This group identified by fluorescent in situ hybridization
with fluorochrome-labeled probes for BCR and ABL genes.
Clinical and hematologic
features
Chronic Phase Disease
Clinical features:

splenomegaly, hemorrhage, or anemia, but many are diagnosed only as a

result of routine blood tests.
 Symptoms when present include lethargy, loss of energy, shortness of breath
on exertion, weight loss, and hemorrhage from various sites. Increased
sweating is characteristic.
 The patient may have severe pain or discomfort in splenic area, often
associated with splenic infarction, or have noticed a mass in left upper
abdomen
The liver is frequently also enlarged. Very high leukocyte count may produce
features of leukostasis with retinal vein engorgement and respiratory
insufficiency.
 
 Hematologic values
Patients with splenomegaly are usually anemic, where as the
hemoglobin concentration may be normal in patients with
early disease.
The leukocyte count at diagnosis is usually between 20 and
200×109/L, but the diagnosis of CML can be established in
patients with persistent leukocytosis in range 12 to 20×109/L.
occasionally patients present with leukocyte numbers above
200×109/L, very rarely above 500×109/L. The Platelet numbers
are usually high in range of
300 to 600×109/L, but may
be normal or even reduced.
Advanced phase disease
Clinical features
In some cases the patient is asymptomatic and
diagnosis is based on blood and marrow finding.
 In other patients may develop fevers, excessive
sweating, anorexia, weight loss, bone pain.
Occasionally, patient presents with generalized
lymphadenopathy
 Hematologic values

 Blastic transformation is defined by presence of more

than 20% in marrow and blood.

 About 70% of patients have that resemble cells that

characterize acute myeloid leukemia.

 20% of patients have lymphoid blast cells.

 10% have mixed lymphoid and myeloid characteristics.

Treatment
 Chronic phase disease
Chemotherapy
Imatinib mesylate: the single most important agent for chronic-
phase disease. Imatinib is an ABL tyrosine kinase inhibitor
Interferon Alfa: it has anti viral and antiproliferative properties.
Hydroxyurea: targets mature progenitors in proliferative cycle.
Busulfan: infrequently used now as profound leukopenia is
produced

Stem cell transplantation

Allogeneic SCT: many patients recovered to normal hematopoiesis, with

disappearance of both their leukemia and PH chromosome.

Autologous SCT: Early in the course of CML leukemia stem cells coexist
with normal stem cells.
Advanced phase disease
Chemotherapy

Patients may be managed with minor alteration in their cytotoxic drug

regimen.
 Myeloid transformation can be treated with drugs used to induction
remission in acute myeloid leukemia
Lymphoid transformation can be treated with drugs used in
management of adult acute lymphoblastic leukemia

Stem cell transplantation

Allogeneic SCT can be performed in accelerated-phase CML. SCT

performed in overt blastic transformation nearly always fails.
Variants of chronic
myeloid leukemia
 Chronic myelomonocytic leukemia
The patient may present with features of anemia or
hemorrhage. The spleen is typically enlarged thus the clinical
picture superficially resembles CML. Marrow cells lack Ph
chromosome. Blood monocytes as high as 50×109/L.

Chronic Neutrophilic Leukemia:

Rare disorder usually diagnosed incidentally. The patient has
raised blood neutrophil count without mature granulocyte
nor basophilia or eosinophilia
EOSINOPHOLIA, BASOPHILIA &
MONOCYTOSIS
MOHAMED SABER METWALI (964)
 Eosinophilia
Eosinophilia is a condition in which the eosinophil
count in the peripheral blood exceeds 450/μl.
Causes:
1. Parasitic infection e.g. :filariasis , shistosomiasis ,
facioliasis ,hook worm ,ascariasis and toxocariasis.
2. Allergic disorders as :bronchial asthma ,hay fever, allergic
vasculitis
3. Recovery from acute infection.
4. Skin diseases as : eczema.
5. Pulmonary esinophilia as: loffler's syndrome(ascariasis).
6. Hyperesinophilic syndrome .
7. Polyarteritis nodosa .
8. Other malignant diseases as: Hodgkin disease,
angioimmunoblastic lymphadenopathy, metastatic
carcinoma
 Basophilia
Basophilia is a condition where the basophil quantity
is abnormally elevated (more than 1010 basophils per liter
of blood)
Basophils in peripheral blood
resemble tissue mast cells both:
i. Release histamine.
ii. Have receptors for IgE and participate in the
degranulation of white blood cells that occurs during
allergic reactions, including anaphylaxis 
Causes:
1. Hypersensitivity states.
2. Rheumatoid arthritis, chronic
ulcerative colitis .
3. Viral infection
4. Post irradiation.
5. in neoplastic disorders.
 Monocytosis
Monocytosis is an increase in the number of
monocytes circulating in the blood
Above 950/μL which is
considered as the upper
limit of normal.

Monocytes are white blood cells that give rise to

macrophages and dendritic cells in the immune
system.
 Causes:
Monocytosis often occurs during
chronic inflammation
Infections: tuberculosis, brucellosis, subacute
bacterial endocarditis, syphilis, and other viral infections
and many protozoal and rickettsial infections (e.g.
malaria).
Blood and immune causes: chronic neutropenia and
myeloproliferative disorders
Autoimmune diseases and vasculitis: SLE, RA, IBD..
Malignancies: Hodgkin’s disease and certain leukemias ,
such as chronic myelomonocytic leukemia(CMML) and
monocytic leukemia.
Miscellaneous causes: Sarcoidosis and storage lipid
disese.
 LYMPHOCYTOSIS
MOHAMED SABRY AHMED (967)
 Lymphocytosis
Increased blood lymphocyte count
(lymphocytes > 4.0 x109/L in adults
and > 9.0 x109/L in children )
Infections
Pertussis or whooping is frequently accompanied by a
lymphocytosis

Toxoplasmosis may cause lymphocytosis similar to

infectious mononucleosis

Brucellosis and Syphilis may occasionally cause an

atypical lymphocytosis.
Infectious mononucleosis caused by an Epstein-Barr
virus infection of B lymphocytes.

CMV occasionally causes a lymphocytosis with

symptoms similar to IM .

Infectious lymphocytosis It may be related to

coxsackievirus A or B6, echovirus, and adenovirus 12.

HTLV-1 may produce a transient lymphocytosis with

fever, rash, and little lymphadenopathy.
Disorders of the Spleen
Patients who have undergone splenectomy,
or whose splenic function is otherwise
reduced, may have a lymphocytosis.
Lymphoproliferative disorders
i. B cell lymphoproliferative disorders
B cell chronic lymphocytic leukaemia (B-CLL) is
by far the most common

 ii. T cell and NK cell lymphoproliferative

disorders CD4 T cell, CD8 T cell and NK
lymphoproliferative disorders are much less
common than their B cell counterparts
Specific causes of lymphocytosis include:
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Crohn`s disease
Cytomegalovirus (CMV) infection
Mononucleosis
Multiple myeloma
Other viral infections
Tuberculosis
Ulcerative colitis
Vascuilitis
Whooping cough
ACUTE LYMPHOBLASTIC LEUKEMIA
MOHAMED SOBHY (966)
Acute lymphoblastic leukemia (ALL)
 Clonal proliferation and accumulation of
blast cells in blood, bone marrow and
other organs
 Disorder originates in single B or T
lymphocyte progenitor
 Heterogenous disease with different
biological subtypes
 Incidence : peaks between age 2 age 4
slightly more in boys and much lower in black
children than in white children
Acute lymphoblastic leukemia (ALL)
Etiology - unknown
But associated with some risk factors as:
1-Down syndrome .
2-Increased chromosomal fragility (ataxia
telangiectasia & bloom syndrome).
3-Neurofibromatosis
4-Shwach-man syndrome
5-Li fraumeni syndrome
6-klienefelter's syndrome
7-Environmental exposure
8-Twins
Acute leukemias - clinical features
1. Bleeding Petechiae, Ecchymosis.
2. Fever/infection
3. Bone/joint pain
4. Hepatomegaly and splenomegaly
5. Signs of anaemia (pallor, fatigue& dysnea)
6. Lymphadenopathy and anterior mediastinal
mass
7. CNS involvement
Acute leukemias - laboratory findings (1)
1. Blood examination
- Anemia,
- Thrombocytopenia, neutropenia
- Variable leukocyte count, usually increased,
- Blood morphology: presence of blast cells
2. Bone marrow morphology
- Hypercellular with presence of blast cells,
- Suppression of normal hematopoiesis
Acute leukemias - Laboratory findings (3)

3. Cytochemical stains
4. Immunophenotyping
5. Cytogenetics (by flow cytometry) changes
include aneuploidy ,invasion ,deletions
and translocation
6. Molecular studies
Morphologic subtypes of acute lymphoblastic
leukemias (FAB classification)

Subtype Morphology Occurrence (%)

L1 Small round blasts 75
clumped chromatin
L2 Pleomorphic larger blasts 20
clefted nuclei, fine chromatin
L3 Large blasts, nucleoli, 5
vacuolated cytoplasm
Acute lymphoblastic leukemias - reactivity
with cytochemical staining
Subtype Peroxidase or Non-specific Periodic
Sudan black esterase acid-Schiff
L1 - - +++
L2 - - +++
L3 - - +++
 Immunologic classification of acute
lymphoblastic leukemias
B- lineage (80%) Markers
Pro-B CD19(+),Tdt(+),CD10(-),CyIg(-),
Common CD19(+),Tdt(+),CD10(+),CyIg(-),
Pre-B CD19(+),Tdt(+),CD10(+),CyIg(+),SmIg(-)
Mature-B CD19(+),Tdt(+),CD10(±),CyIg(±),SmIg(+)
T-lineage (20%)
Pre-T CD7(+), CD3(-), Tdt(+),
Mature-T CD7(+), CD3(+), Tdt(+),
 Acute leukemias and CNS

leukemic blast cells can be identified in the CSF of one

third of patients at diagnosis, but only 2-3% of patients
have an overt CNS leukaemia with the presence of
cranial palsy.
predicts an increased risk of CNS relapse
Requires more intensive intrathecal therapy
 Various metabolic abnormalities
Hyperurecemia,
hyperphosphatemia,
Elevated serum lactate dehydrogenase (LDH).
The degree of abnormality reflects the leukemic cell
burden and destruction (lysis)
 Differential diagnosis
 Acute myelocytic leukemia
 Non-Hodgkin Lymphoma
 Anemia, Acute
 Osteomyelitis
 Anemia, Fanconi
 Parvovirus B19 Infection
 Juvenile Rheumatoid Arthritis
 Rhabdomyosarcoma
 Leukocytosis
 Mononucleosis and Epstein-Barr Virus Infection
 Neuroblastoma
 Aplastic anemia
 Idiopathic thrombocytopenic purpura (ITP)
Treatment strategy in ALL
 In ALL the choice of treatment-strategy
depends on:

1. Risk qualification
2. Age and biological condition
3. Immunophenotype of leukemic cells
- T lineage,
- early B lineage,
- mature B lineage,
General supportive treatment
Replacement therapy of blood cells may be
required - pre-existing deficiency due to ALL
can be profoundly aggravated by chemotherapy.
Growth factors to alleviate profound
myelosuppression, e.g. (GCSF) during
induction for faster recovery of neutrophils and
platelets, and a shorter hospital stay.
Antibiotics and antifungal agents
Allopurinol during induction therapy to
control uric acid levels.
A central venous catheter is usual, given the
frequent requirements for venous access.
Remission induction therapy in ALL
.To achieve remission or less than 5% blasts in the bone
marrow.
.Drugs: glucocorticoid , vincristine, asparginase,
anthracycline
.Treatment duration: 4-8 weeks
.No of courses: 1- 2
Consolidation and Re-induction in
standard-risk ALL
Soon after remission is achieved
o for 3-6 month
o to further reduce the leukemic cell burden
before the emergence of drug resistance and
relapse
o Consolidation therapy also appears to improve
the long-term survival of patients with
standard-risk disease.
o Regimens commonly : high-dose MTX and 6-MP
or dexamethasone, vincristine, L-asparaginase
and doxorubicin followed by thioguanine,
cytarabine, and cyclophosphamide.
 Maintenance
1) 2.5-3 yrs using daily oral 6-MP at night on empty
stomach and weekly MTX IV

2) Attempts to reduce this time result in high relapse

rates after therapy is stopped
 CNS disease
Treatment of subclinical CNS leukemia is an
essential component of acute lymphoblastic
leukemia therapy.
cranial irradiation effectively prevents overt CNS
relapse
concern about subsequent neurotoxicity and brain
tumors has led to replace irradiation with intensive
intrathecal and systemic chemotherapy for most
patients
 Treatment Of mature B-cell:
Short intensive chemotherapy including high-dose
methotrexate (MTX), cytarabine, and
cyclophosphamide.
Course for 2-8-month.
 Relapse
Relapsed cells acquire resistance to exposed
chemotherapy drugs.
treatment of relapse is intensive and often includes
SCT.
Most patients are referred for trial 'salvage' therapies
…outcome of relapse is poor.
 Prognosis
Overall, the cure rate for childhood acute
lymphoblastic leukemia is more than 80%.
However, the prognosis depends on the clinical
and laboratory features.
In general, the prognosis is best in children aged 1-
10 years.
Adolescents have intermediate outcomes.
Infants younger than 1 year have a poor outcome,
with cure rates of about 30%.
Survivors may experience late effects from
treatment, which involve all organ systems.
Therefore, lifelong follow-up is necessary
 Treatment results in ALL

Adults
Complete remission (CR) 80-85%
Leukemia-free survival (LFS) 30-40%

Children
Complete remission (CR) 95-99%
Leukemia-free survival (LFS) 70-80%
 Complications
1- Tumor lysis syndrome 2- Renal failure
3-Sepsis 4- Bleeding
5-Thrombosis 6- Cognitive defects
7-Neuropathy 8- Encephalopathy
9- Secondary malignancy 10- Seizures
11-Short stature (if craniospinal radiation)
CHRONIC LYMPHOCYTIC LEUKEMIA
MOHAMED SABRY ROSTEM (968)
Chronic lymphocytic leukemia
Chronic lymphocytic leukemia (CLL) is the most
common form of adult leukemia in the Western
hemisphere.

CLL, a chronic malignant disease characterized by a

multitude of clinical features, was initially described as
an accumulative disorder of abnormal lymphocytes.
EPIDEMIOLOGY
• It is diagnosed in about 10,000—15,000 new cases per year in the united States.

• CLL is more frequent in males.

• The median age at diagnosis is approximately 66 years old.

• There have been associations linking CLL to farming and to chemical agents used
in agriculture.

• CLL is one type of leukemia that has NOT been associated with radiation
exposure.

• families have recently been identified with a definite proclivity for developing this
disease.
PATHOPHYSIOLOGY
• The transforming event to neoplasia occurs in a
common lymphocyte precursor cell (CLP). In
utero, all fetal B cells are CD5+ve. This proportion
of cells markedly declines in number after birth.

• The CLP cell undergoes change resulting in a

monoclonal population of B cells with a
characteristic antigenic expression pattern. The
leukemic cells are identified by CD5+CD19+CD23+
features.

• although the leukemic cells have difficulty in

undergoing apoptosis related to the expression of
specific antiapoptotic proteins (e.g., Bcl-2. Mcl-1,
etc.), there is also a proliferative compartment
resulting in an overproduction of the malignant
cells.
• Circulating malignant B cells are
frequently seen in this disease, and
most organs are infiltrated with
these cells.

• Accumulation of the cells within

the bone marrow results in
ultimate progressive infiltration,
– The bone marrow pattern initially
may be interstitial,
– and then will develop nodular
infiltrates that are nontrabecular.
– As the disease burden progresses,
the bone marrow will become
diffusely infiltrated, resulting in
anemia, thrombocytopenia, and
neutropenia.
CLINICAL FEATURES AND DIAGNOSIS
• Symptoms and Signs
– No symptoms or signs of disease
(30-50% of patients at
presentation).

– Fatigue (most common symptom

either with or without anemia).

– Organ enlargement (lymph

nodes, splenomegaly,
hepatomegaly).

– Fever, night sweats, or weight

loss.
Complications
• Frequent infections (most common cause of serious
morbidity & death).

• Dysregulated immune system (e.g.. Evans's syndrome,

hemolytic anemia & immune thrombocytopenia,
paraneoplastic pemphigus, pure red cell aplasia).

• Secondary malignancies.

• Transformation to high-grade hematologic malignancy

(e.g..Richter's syndrome with large-cell lymphoma,
CLL/prolymphocytic transformation).
Laboratory Features
• Blood count.
– Hb normal or low;
– WBC raised, and may be very
high; with lymphocytosis
(criteria for diagnosis > 5 ×
109/L),
– platelets normal or low.

• Blood film.
– Small or medium sized
lymphocytes.
– May see smudge cells in vitro.
• Bone marrow.
– > 30% lymphoid cells on aspirate;
– biopsy will show nodular, interstitial or diffuse pattern of infiltration

• Immunophenotyping shows mainly CD19+, CD5+, CD23+ with a weak

expression of CD20 and CD79b and surface immunoglobulin (kappa
and lambda light chains).

• Coombs' test. May be positive if there is haemolysis.

• Hypogammaglobulinemia (about 60% of patients).

 DIFFERENTIAL DIAGNOSIS
        Positive Markers[*]
Cell of CD19,
Lymphaden Splenomega Origin CD20
Disease opathy (%) ly (%) (B/T) SmIg CD5 (%) Other
Chronic 75 50 B (20:1) Weak >90% ≥90 Mouse red blood cell
lymphocytic receptors
leukemia
(CLL)
Prolymphoc 33 95 B (4:1) Bright T-cell PLL 75 FMC-7
ytic
leukemia
High peripheral
(PLL)
lymphoid cell
count
Hairy cell <10 80 B (T rare) Bright — >90 CD25, CD11C, CD103
leukemia
Lymphoid cells an
irregular outline
owing to the presence
of filament-like
cytoplasmic
projections
Prognostic Features
• Classic Clinical Staging Systems
– Modified Rai or Binet Systems
– Bone marrow pattern of lymphoid cell infiltration
(diffuse worse than nodular/interstitial)
– Increased number of prolymphocytes in peripheral
blood
– Increased serum markers reflecting disease burden
(lactate dehydrogenase, β2-microglobulin, soluble
CD23, and thymidine kinase)
– Lymphocyte doubling time (<6-12 months)
• Additional Prognostic Features
– Chromosomal abnormalities: del(17pl3.1); del (11q22.3);
trisomy 12ql3; normal cytogenetics, and del(13q14)

• Mutation or deletion p53 gene

– High percentage of lymphoid cells positive for CD38
expression (should gate on CD5, CD19, and CD20
populations)
– Mutational status of Ig VH genes (unmutated worse than
mutated)
– ZAP-70 protein expression high in CLL cells (research
test not yet validated by' commercial laboratories
 A high-risk patient
• unmutated Ig VH gene;

• FISH demonstration of cells with either 17p deletion or

11q23 deletion;

• cells highly positive for CD38 expression

• or for ZAP-70 protein expression.

System and Risk Manifestations Percent of Median survival Recommended
stage patients (years) treatment

Rai staging system

0 Low Lymphocytosis 31 > 10 Watch and wait

I Intermediate Lymphadenopathy 35 9 Treat only with

progression†

II Intermediate Splenomegaly, 26 7 Treat only with

lymphadenopathy, progression†
or both

III High Anaemia, 6 5 Treatment

organomegaly indicated in
most cases

IV High One or more of the 2 5 Treatment

following: indicated in
anaemia, most cases
thrombocytopenia
and organomegaly
 Binet staging system

A Low Lymphocytosis, 63§ > 10 Watch and wait

< 3 lymphoid
areas enlarged‡

B Intermediate ≥ 3 Lymphoid 30 7 Treatment

areas enlarged‡ indicated in
most cases

C High Anaemia, 7 5 Treatment

thrombocytope indicated in
nia or both most cases
 TREATMENT
• General/supportive treatment
– Anaemia due to haemolysis is treated with steroids.
– If it is refractory or recurrent, or if splenic discomfort is a problem, a
splenectomy is performed.

– Anaemia and thrombocytopenia due to marrow infiltration is

treated with chemotherapy and, when necessary, transfusion.

– Infection is treated with antibiotics, with prophylactic therapy being

given during periods of chemotherapy. Immunoglobulin replacement
may be helpful.

– Allopurinol is given to prevent hyperuricaemia.

Specific treatment
• In older patients requiring control of bulk disease or
progressive elevation of their counts, the use of either
chlorambucil or cyclophosphamide has been
effective.
• It was reported that fludarabine was useful in
achieving responses in heavily treated patients.
• Several studies show that combined therapy using
either fludarabine and simultaneous Rituxan or
fludara­bine and cyclophosphamide produce a
higher complete response rate than fludarabine alone.
• The triple combination of fludarabine,
cyclophosphamide, and Rituxan produced the
highest complete response rate yet.
• Bone marrow transplantation using either
allogeneic or autologous.