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Color Atlas ofHematology
PracticalMicroscopic and Clinical Diagnosis
Harald Theml,M.D.
Professor, Private Practice
Hematology/Oncology
Munich, Germany
Heinz Diem,M.D.
KlinikumGrosshadern
Institute of Clinical Chemistry
Munich, Germany
Torsten Haferlach,M.D.
Professor, KlinikumGrosshadern
Laboratory for Leukemia Diagnostics
Munich, Germany
2nd revised edition
262 color illustrations
32 tables
Thieme
Stuttgart · New York

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Color atlas of hematology-Practical microscopic and clinical diagnosis 2e 2004
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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:PolychromaticandOrthochromaticErythroblasts(Normobl​asts)andReticulocytes . . . . . . . 32
ImmatureWhiteCellPrecursors:MyeloblastsandPromyelocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Theml, Color Atlas of Hematology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
viii
PartlyMatureWhiteCellPrecursors:MyelocytesandMetamyelocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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.,HairyCellLeukemiaandSplenicLymphomawithVil​lousLymphocytes) . . . . . . . 80
MonoclonalGammopathy(Hypergammaglobulinemia),MultipleMyeloma*,PlasmaCellMyeloma,​Plasmacytoma . . . . . . . . . 82
VariabilityofPlasmacytomaMorphology. . . . . . . . . . . . . . . . . . . . . 84
RelativeLymphocytosisAssociatedwithGranulocytopenia
(Neutropenia)andAgranulocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
ClassificationofNeutropeniasandAgranulocytoses . . . . . . . . . . . 86
Monocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
AcuteLeukemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
MorphologicalandCytochemicalCellIdentification . . . . . . . . . . . 91
AcuteMyeloidLeukemias(AML) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
AcuteErythroleukemia(FABClassificationTypeM6) . . . . . . . . . . 100
AcuteMegakaryoblasticLeukemia
(FABClassificationTypeM7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
AMLwithDysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
HypoplasticAML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Contents
Theml, Color Atlas of Hematology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
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
BoneMarrowCytologyintheDiagnosisofHypochromicAnemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
HypochromicSideroachresticAnemias(SometimesNormochromicorHyperchromic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
HypochromicAnemiawithHemolysis . . . . . . . . . . . . . . . . . . . . . . . . . 138
Thalassemias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
NormochromicAnemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
NormochromicHemolyticAnemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
HemolyticAnemiaswithErythrocyteAnomalies. . . . . . . . . . . . . . . . 144
NormochromicRenalAnemia(SometimesHypochromicor
Hyperchromic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
BoneMarrowAplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
PureRedCellAplasia(PRCA, Erythroblastopenia) . . . . . . . . . . . . . 146
AplasiasofAllBoneMarrowSeries(Panmyelopathy, Panmyelophthisis,AplasticAnemia). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
BoneMarrowCarcinosisandOtherSpace-OccupyingProcesses . . 150
HyperchromicAnemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
ErythrocyteInclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
HematologicalDiagnosisofMalaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Contents
Theml, Color Atlas of Hematology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
PolycythemiaVera(ErythremicPolycythemia)
andErythrocytosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
ThrombocyteAbnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
ThrombocytopeniasDuetoIncreasedDemand
(HighTurnover) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
ThrombocytopeniasDuetoReducedCellProduction . . . . . . . . . . 168
Thrombocytosis(IncludingEssentialThrombocythemia) . . . . . . . . 170
EssentialThrombocythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
CytologyofOrganBiopsiesandExudates . . . . . . . . . . . . . . . 173
LymphNodeCytology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
ReactiveLymphNodeHyperplasiaandLymphogranulomatosis
(HodgkinDisease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
SarcoidosisandTuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Non-HodgkinLymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
MetastasesofSolidTumorsinLymphNodesorSubcutaneous
Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
BranchialCystsandBronchoalveolarLavage . . . . . . . . . . . . . . . . . . 184
BranchialCysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
CytologyoftheRespiratorySystem,EspeciallyBronchoalveolar
Lavage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
CytologyofPleuralEffusionsandAscites . . . . . . . . . . . . . . . . . . . . . 186
CytologyofCerebrospinalFluid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
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