Blood examination for Veterinary Hematology pathology/chaleaw/vicha nisit4-2562/6RA_62.pdfPolychromasia, metarubricytosis ( NRBCs), H-J bodies RA Extra- or Intra-HA Differentiation

เอกสารประกอบการสอนวชา 01534411 - ศ.สพ.ญ.ดร.เฉลยว ศาลากจ

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เฉลยว ศาลากจ

ภาควชาพยาธวทยา คณะสตวแพทยศาสตร

มหาวทยาลยเกษตรศาสตร อ.กาแพงแสน

Veterinary HematologyRegenerative Anemia (RA)

บทท 9 หนา 95-108

Blood examination for

1. Screening procedure to assess general health,

2. Patient evaluation or diagnosis,3. Assess the body’s ability to fight infection,

4. Evaluate the progress of certain disease’sstate

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Contents

• Anemia

• Regenerative anemia (RA)

• Blood loss anemia

• Hemolytic anemia (HA)

• Extra-vascular HA

• Intra-vascular HA

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Anemia & Polycythemia

Anemia

• decrease RBC mass (PCV)

• Clinical sign

–Pale – Weakness

– loss of stamina

– exercise intolerance

– Tachycardia ect.

• Icterus, Hburia, Hemorrhage, fever.

Polycythemia

• increase RBC mass

• Clinical sign – Pink mucous membrane

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Regenerative anemia (RA) ?

Non-regenerative anemia (NA) ?

Blood Loss

Hemolytic Anemia

Macrocytosis: (RBC size) = MCV

ขาดธาตอาหาร: iron, copper,

b12, b6, niacin, vitamin E,/C

Anemia of Chronic Disease

โรคไต

โรคของไขกระดก Hyperthyroidism

Liver disease5

Anemia

Regenerative anemia = RA

• Increase production of RBC

• Findings

– polychromasia,

– Reticulocytosis,

– macrocytosis & hypochromia

– hyper-cellular BM

Non-regenerative anemia = NA• BM disorder

• no polychromasia & reticulocytosis

• 2-3 days after per-acute or acute hemorrhage

• BM exam. = helpful in some cases

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Dog, PCV 36% (N 30-48), MCV 78 fL (N 60-70)

Polychromasia, macrocytosis, reticulocytosis

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Regenerative anemia = extra-marrow cause

Hemorrhagic anemia

Clinical findings acute blood loss

• Direct evidence of hemorrhage, may be occult.

– GI hemorrhage

– Thrombocytopenia & abnomal clotting test

– Thrombocytopenia alone is not existent

Hemolytic anemia

• Extra-vascular hemolysis• Intra-vascular hemolysis

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Lab. Findings of acute blood loss1. Initially, normal PCV, hypovolumic shock

2. Splenic contraction = high PCV (80%) = temporary of PCV

3. 2-3 hr to 2-3 ds. = addition of interstitial fluid = anemia, PP

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6. Polychromasia, reticulocytosis 48-72 hr. max. at 7 ds.

4. Plt. No. increase 2-3 ชวโมงแรก ถา persistent thrombocytosis เปนตวบงชถง continue bleeding

5. Neutrophilia common 3 hr. post-hemorrhage.

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1. regenerative response but < acute

2. Hypoproteinemia (PP decrease)

Lab. findings of chronic blood loss

3. Persistent thrombocytosis (platelets)

4. อาจพบ iron def. anemia = microcytichypochromic RBCs

สนข (เพศผ 9 m) Hemogram คาอางอง

PCV (%) 21 30-45

MCV (fL) 57 60-70

MCHC (gm %) 34.5 32-36

WBC (x103/µL) 18.320 6.0-17.0

Band % - 0-0.300

Segment % (x103/µL) 67 (12.261) 3-11.5

Lymph 23 (4.214) 1-4.8

Mono 8 (1.466) 0.15-1.3

Eos 2 (0.366) 0.1-1.2

Baso - rare

Plasma protein (g/dL) 9.2 6.0-7.5

Platelets (x105/µL) 0.21 2.0-9.0

Suspect BP ?

Anemia microcytic

Slightly leukocytosis

•Mild neutrophilia

Thrombocytopenia

Hyperproteinemia

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Dx: ?

WBCHyperproteinemia

microcytic /hypochromic iron def.

Nucleated RBC

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reutilized of iron, PP in internal hemorrhage

External VS internal hemorrhage

anemia may not severe in internal hemorrhage

Anemia

RA or NA

Polychromasia, metarubricytosis( NRBCs), H-J bodies

RA

Extra- or Intra-HA

Differentiation of Anemia

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Characteristic of HAA. Clinical findings

1. No sign of hemorrhage

2. severity of anemia

3. Icterus in acute & severe cases

Anemia from accelerated RBC destruction; Hemolytic anemia (HA)

4. Hburia & Hbemia พบในกรณของ intravascular hemolysis

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1. ret. count in hemolytic anemia > external hemorrhage

2. PP = N or increase

Lab. findings of HA

3. อาจพบ Neutrophilia & monocytosis

4. Evidence of Hb degradation

hyperbilirubinemia, Hburia

- Heinz bodies

- RBC parasites

- Spherocytes

- poikilocytosis

5. Abnormal RBC morphology

Babesia canis

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- mechanism of destruction

- site intra - or extra-hemolysis

Differentiation the cause of HA

- predominate- predominate

Clinical signs & lab. Findings of Hemolytic anemia

Extra-vascular hemolysis1. chronic, insidious onset

2. N or PP

3. no Hbemia & Hburia

4. hyperbilirubinemia, conjugate & excreted by liver, early unconjugated bilirubin

5. Neutrophilia, monocytosis, thrombocytosis = common.

Intra-vascular hemolysis1. peracute or acute

2. history = drugs or plants, transfusion, colostrum

3. regenerative response ไมเดนชด

4. Hbemia ซงตรวจพบโดย red plasma, MCHC

5. Hburia 12-24 hr. following hemolysis

6. Hyperbilirubinemia in some cases unconjugated bilirubin = early เทานน หลงจากนน จะเปน conjugatedbilirubin

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Pre-hepatic jaundice Hepatic jaundice

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Extra-vascular hemolysis1. Ab and/or C3 mediated

2. Decreased RBC deformity3. Reduced glycolysis & ATP in RBC

4. Increased macrophage activity

Intra-vascular hemolysis1. C’-mediated lysis

2. Physical injury

3. Oxidative injury

4. Osmotic lysis

5. Membrane alteration

Mechanisms of Hemolytic anemia

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1) Ab ตอ RBC memb. Ag, Ag ทตดแนนกบ RBC, Ag-

Ab cpx ทตดแนนกบ cm

2) C3 fixation Ag-Ab cpx หลดเหลอแต C3

RBC = innocent bystander

a. Ab and / or C3 mediated

3) macrophage complete or partial phagocytosis ในกรณของ partial phagocytosis จะได spherocytes


Intra-vascular hemolysis

Extra-vascular hemolysis

Spherocytes

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Villiers E and Blackwood L. 2005. BSAVA Manual of Canine and Feline Clinical Pathology. 2nd ed. P. 42.

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a. Unknown (Auto-immune HA, IdiopathicAHA)

b. Infectious agents (FeLV, EIA virus, Ehrlichia, Mycoplasma or Hemobartonella)

i. ปป RBC mb ทาให Ag ทรางกายสราง Ab โผลออกมาii. Immune cpx ทตดกบ RBC สามารถ fix C3iii. อาจเกด cross-reacting Ab ในการตอบสนองตอการตดเชอ

4) immune-mediated anemia อาจเกดจาก


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c. Penicillin = hapten

d. Alteration in immune system

- T-cell fc. เสยไป เกด disrupt immune reg.

- lymphoid malignancy อาจตรวจพบ Coombs’+ anemia

5) Coombs’ test; warm -active IgG, IgG + C3C3 alonecold-active IgM

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Coombs’ reagent

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Villiers E and Blackwood L. 2005.

BSAVA Manual of Canine and Feline Clinical

Pathology. 2nd ed. P. 44.

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1. Cell membrane change, internal viscosity, surface area/volume ratio

2. ถกกาจดโดย splenic & sequestationphagocytosed by macrophage

1. Schistocyte of microangiopathicanemia

2. Spherocyte of immune-mediated hemolytic anemia

3. Parasitzed RBC

4. Eccentrocytes or Heinz body-containing RBCs

Extra-vascular hemolysis2. Decreased RBC deformability

Swine schistocytes

Dog’s Heinz bodies29 3030

1) ถกกาจดโดย splenic macrophages

2) glycolysis พบใน normal aging

3. Reduced glycolysis & ATP in RBC

3) อตราการลดลงเรวมากในhereditary pyruvate kinase def.& phosphofructokinase def.


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1. ถาเกด excessive activity ของ macrophage อาจเกดการจบกน normal RBC

2. splenomegaly

4. Increased macrophage activity

3. ในคนเรยกภาวะนวา hypersplenism

สาเหตททาใหเกด intravascular hemolysis ไมทาให RBC แตกหมด อาจถกกาจดโดย phagocytosis

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a. breed or litter mates

- Cocker, English Springer spaniels, = phosphofructokinase def. anemia

- Basenji, beagles = pyruvate kinase def. anemia

b. additional lab. findings - Coombs’ test

Aids in identification of specific cause of extravascular hemolysis

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- RBC parasites,

- spherocytes

- schistocytes

& keratocytes

TEM of splenic endothelium and RBC

Abnormal RBC morphology

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a. chronic, insidious onset

b. N or PP

c. no Hbemia & Hburia

Clinical & lab. Character of phagocytic hemolysis

d. hyperbilirubinemia, conjugate & excreted by liver, early unconjugated bilirubin

e. BM response, low-grade hemolysis = PCV normal compensated HA. f. Neutrophilia, monocytosis, thrombocytosis = common.

g. splenomegaly อาจเกดจาก macrophage activity & extramedullary hematopoiesis

h. low-grade extra-vascular hemolysis อาจเกดจาก1o non-hemolytic (chronic renal dz., iron-lack anemia) = hemolytic component of other type of anemia

Clinical & lab. Character of phagocytic hemolysis Intra-vascular hemolysis

1. Complement-mediated lysis

2. Physical injury

3. Oxidative injury

4. Osmotic lysis

5. Membrane alteration

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1. Complement-mediated lysis1. Complement-mediated lysis

• Ag-Ab complex กระตนถง C9 เกด memb. defect = Hbleak

• IgM = a good C’ fixer

• พบในกรณ– neonatal isoerythrolysis,

– transfusion reactions,

– ในบางรายของ AIHA ทเกดจาก IgM

• ถากระตนถง C3 = phagocytosis

Intra-vascular hemolysisIntra-vascular hemolysis

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2. Physical injury2. Physical injury• shearing effect of fibrin

• fibrin สวนใหญเกดใน small bv =

microangiopathic anemia

• พบในกรณ - DIC,

– vasculitis,

– heart worm

• schistocytes or keratocytes

Canine schistocytes


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Fig. 4-53 Drawing of schistocytesand microspherocyteformation when an erythrocyte impact fibrin strand under flow condition.

J.W. Harvey. 2012. Veterinary Hematology: A diagnostic Guide and Color Atlas.

Oxidative injury3. Oxidative injury• drug or diet

derivatives ทรบกวนการสราง reduced glutathione

• Heinz body

or eccentrocytes(arrows)


Dog40

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a. reduced glutathione ทาหนาท neutralized oxidant และคงสถานภาพไดโดย hexosemonophosphate pw.

การขาด enzyme or intermediate (เชน glucose-6-phosphate dehydrogenase, G6PD) ทาใหเกด memb. oxidation & Heinz body formation

การปองกน RBC จาก oxidant 2 ทางคอ

b. MetHb reductase ทาหนาท reduced iron & มMetHb จานวนนอย มรายงานการขาด enz. ในสนข

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Osmotic lysis 4. Osmotic lysis • Membrane alteration

• hypotonic intravenous fluid

• Water intoxication = calves, not fatal

• มสาเหตคลาย extravascular hemolysis มแตมผลทาใหเกด osmotic lysis กอนเกดphagocytosis



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5. Membrane alterations• Caster beans ทมยาง (ricin) มผลทา

ใหเกด direct lysis

• snake venoms = lysis RBC

• bacterial toxin เชนphospholipase of Clostridium novyi ทาลาย membrane lipids โดยตรง

• Babesia sp. disrupt memb. on exiting

Babesia canis

Intra-vascular hemolysis

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a. peracute or acute

b. history = drugs or plants, transfusion, colostrum

Clinical & lab. character of intravascular hemolysis

c. regenerative response ไมเดนชด

d. Hbemia ซงตรวจพบโดย

- red plasma

- increase MCHC

-serum haptoglobin & hemopexin

e. Hburia 12-24 hr. following hemolysis

f. Hemosiderinuria

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- bilirubin จะสราง 8-10 hr. ภายหลง hemolysis

- เกดเมอตบไมสามารถกาจด bilirubin ออกจาก

plasma, conjugate & excrete into the bile

g. Hyperbilirubinemia

- unconjugated bilirubin = early เทานน หลงจากนน

จะเปน conjugated bilirubin

Clinical & lab. character of intravascular hemolysis

• RA or NA ดจาก 1. Polychromasia2. Reticulocytosis3. Increase H-J bodies4. Increase NRBC

• PP low or high• Platelets count

Conclusion = Differentiation of Anemia

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Documents

Blood examination for Veterinary Hematology pathology/chaleaw/vicha nisit4-2562/6RA_62.pdfPolychromasia, metarubricytosis ( NRBCs), H-J bodies RA Extra- or Intra-HA Differentiation