Hematology

• Blood is a moving tissue that circulates in a closed system of blood vessels and the heart (Cardiovascular
system).
• The chief function of blood is transport of O2 and nutrients to all the cells of the body, and CO2 and waste
materials to the organs of excretion.
• Blood and the cardiovascular system constitute the circulatory system.

Components of Blood

Cellular Components
• Red Blood Cells (RBCs): These cells, also called erythrocytes, are responsible for transporting oxygen from
the lungs to the rest of the body and carrying carbon dioxide back to the lungs for exhalation.
• White Blood Cells (WBCs): Also known as leukocytes, these cells play a crucial role in the immune system,
defending the body against infections and foreign substances. There are different types of WBCs, such as
neutrophils, lymphocytes, monocytes, eosinophils, and basophils, each with specific functions.
• Platelets: These are small cell fragments that help in blood clotting. When a blood vessel is injured,
platelets accumulate at the site to form a clot and prevent excessive bleeding.
Fluid Component:
• Plasma: This is the liquid portion of blood, making up about 55% of the total blood volume. It is a yellowish
fluid (due to the presence of bilirubin) composed of water, electrolytes, proteins, hormones, and waste
products. Plasma serves as a medium for transporting blood cells, nutrients, gases, and waste materials
throughout the body.
Physical Properties of Blood
1. Color
▪ Bright Red – oxygenated blood
▪ Purplish red – deoxygenated blood (carbon dioxide)
▪ Cherry red (CO) – carboxyhemoglobin
▪ Plasma (bilirubin) – yellow
2. Opacity
▪ Opaque due to the suspension of cells in the plasma
3. Viscosity
▪ Due to RBCs
▪ Blood – 3-5 times as viscous as water
▪ Plasma – 1.8 times as viscous as water
4. Osmotic pressure of plasma
▪ 290±5 mosm/kg
• 270 mosm/kg: due to Na+ and its anions
• 10 mosm/kg: due to glucose and urea
• <2 mosm/kg: due to plasma proteins
▪ 0.9% NaCl and 5% dextrose solution
5. Suspension stability of RBC
▪ In the living body, RBC are suspended in the plasma (center of bloodstream)
▪ In vitro, RBC will gradually settle leaving a clear column of plasma above.
6. Red Cell Fragility (Osmotic Fragility)
▪ Hemolysis is the escape of red cell contents into the surrounding solution as a result of red cell
membrane disruption.

▪ When osmotic fragility is normal, hemolysis

• Starts at 0.5% NaCl solution
• Is completed at 0.35% NaCl solution
▪ Osmotic fragility is increased in
• Hereditary spherocytosis
• G6PD deficiency

Blood Volume
• Blood volume refers to the total amount of blood circulating within the cardiovascular system. It can vary
among individuals based on factors such as age, sex, body weight, and overall health.
• Average Blood Volume
• The average blood volume in adults is approximately 4.5 to 6 liters.
• 8% of body weight
• Physiological Variations
• Age: Blood volume tends to increase with age, reaching its peak in middle age.
• Sex: Adult males generally have a higher blood volume than females. This is often attributed to
differences in body size and composition.
• Lean body mass: Blood volume is proportional to body weight. Individuals with higher body weight
tend to have a larger blood volume.
• Fitness Level: Regular physical activity and cardiovascular fitness can influence blood volume. Athletes
may have higher blood volumes to meet the increased oxygen-carrying demands of their active muscles.
• Pregnancy: Blood volume significantly increases during pregnancy to support the growing fetus and
placenta. This adaptation helps meet the increased oxygen and nutrient requirements. It reaches
maximum at 38th week of gestation.
 • Posture: supine > standing by about 15%
• Nutritional status: reduced in starvation
• Regulation of Blood Volume
• The body tightly regulates blood volume to maintain homeostasis.
• Hormones such as antidiuretic hormone (ADH), aldosterone, and atrial natriuretic peptide (ANP) play
crucial roles in controlling blood volume by influencing fluid balance and kidney function.
• Measurement of Blood Volume
• Blood volume can be estimated using various techniques, including dilution methods and radiolabeled
tracers.

Red Blood Cells (Erythrocytes)

Structure of Erythrocytes
• Cell Shape: Erythrocytes are small, biconcave disc-shaped cells. The biconcave shape provides a large
surface area for oxygen and carbon dioxide exchange and allows flexibility to navigate through narrow
capillaries.
• Lack of Nucleus: Mature erythrocytes lack a nucleus and most organelles, including the endoplasmic
reticulum and mitochondria. This absence of a nucleus maximizes the space available for hemoglobin, the
oxygen-carrying molecule. Lack of mitochondria makes RBC solely reliant on glycolysis for energy.
• Hemoglobin Content: The primary component of erythrocytes is hemoglobin, a protein that binds with
oxygen in the lungs and releases it in tissues. Hemoglobin gives blood its red color.
Function of Erythrocytes
• Oxygen Transport: The main function of erythrocytes is to transport oxygen from the lungs to tissues and
organs. Hemoglobin binds with oxygen in the lungs, forming oxyhemoglobin, which is then carried by
erythrocytes through the bloodstream.
• Carbon Dioxide Transport: Erythrocytes also play a role in carrying carbon dioxide, a waste product of
cellular metabolism, from tissues back to the lungs for exhalation. Carbon dioxide binds with hemoglobin or
is transported in the blood as bicarbonate ions.
• Buffering Capacity: Erythrocytes (globin chain) contribute to the blood's acid-base balance by acting as
buffers. They can absorb and release hydrogen ions, helping to maintain the optimal pH of the blood.
• Flexibility and Circulation: The biconcave shape and flexibility of erythrocytes allow them to squeeze
through narrow capillaries, facilitating their movement through the circulatory system. The assume an
elongated parachute when they pass through the capillaries.

Physiological Variations
• Age
• Children < adult
• Gender
• Adult males generally have a slightly higher RBC count than females. This is partly due to hormonal
differences and the influence of testosterone on erythropoiesis, the process of RBC production.
• Altitude
• At higher altitudes, where oxygen levels are lower, the body may respond by producing more RBCs to
enhance oxygen-carrying capacity. This adaptive response helps individuals cope with reduced oxygen
availability.
• Physical Fitness and Training
• Regular physical activity and aerobic exercise can stimulate the production of RBCs, enhancing oxygen
transport to muscles. Athletes, especially those engaged in endurance sports, may have a higher RBC
count.
• Pregnancy
• During pregnancy, blood volume increases to support the growing fetus. While plasma volume rises
more than RBC mass, leading to a dilutional effect (relative decrease in RBC count), the total RBC count
may still show a mild increase.
• Posture
• Recumbent < upright count
• Diurnal (circadian) variation
• Highest in the morning and lowest in the evening
• Day to Day Variation
• Lowest just before menstruation (hemodilution effect)
• Pregnancy
• Relative decrease in RBC count (hemodilution effect)

Pathological Variations
• All types of anemia: absolute decrease in RBC count (common)
• Polycythemia: absolute increase in RBC count (rare)
• Dehydration: relative increase in RBC count (common)
• Hemodilution: relative decrease in RBC count
• Smoking: Smoking has been associated with a higher RBC count. Nicotine in tobacco smoke can stimulate
the release of erythropoietin, a hormone that regulates RBC production.

Erythropoiesis
Intrauterine life (fetal life)
• Up to 2nd month: yolk sac
• 2nd to 7th month: liver and spleen
• 7th to 9th month: bone marrow

After birth
• Infancy (up to 1 year): throughout the skeleton
• At the age of 7 years: marrow becomes slightly fatty and activity begins to decline
• More than 20 years: mainly in flat bones, and red marrow of upper ends of humerus and femur

Extramedullary Hemopoiesis
• Organs other than bone marrow: liver and spleen
• Diseases in which the bone marrow is destroyed or fibrosed
• When demand for RBCs exceeds supply by the bone marrow (e.g., erythroblastosis fetalis)

Duration of Erythropoiesis
• 7-10 days
• Life span of RBCs – 80-120 days
Stages of Erythropoiesis

• Totipotent Uncommitted Stem Cells

• Definition: Totipotent stem cells have the highest developmental potential and can differentiate into
any cell type, including the cells that make up the entire organism and support structures such as the
placenta.
• Characteristics: Totipotent cells can give rise to both embryonic and extraembryonic cell types.
• Example: The zygote, formed by the union of a sperm and egg during fertilization, is considered
totipotent. It has the potential to develop into a complete organism and the supporting structures
needed for embryonic development.
• Hematopoietic Stem Cell (HSC) or Pluripotent uncommitted stem cell
• Erythropoiesis begins with the hematopoietic stem cell, a multipotent cell found in the bone marrow.
Hematopoietic stem cells have the ability to differentiate into various blood cell types.
• Unipotent Committed Stem Cell (or) Erythroid stem cells
• In the presence of erythropoietin, HSC differentiates into unipotent committed stem cell.
• Proerythroblast
• Proerythroblasts are large cells with a large nucleus and basophilic cytoplasm.
• Early Normoblast
• Intermediate Erythroblast
• Hemoglobin synthesis begins
• Late Normoblast
• Hemoglobinization ++
• Nuclear disintegration
• Reticulocyte
• Hemoglobinization +++
• Residual ribosomal RNA left as reticulum.
• They leave the bone marrow to the blood stream by diapedesis.
• Mature Red Blood Cell
• Description: Reticulocytes mature into fully functional red blood cells.
• Characteristics: Mature red blood cells lose their remaining organelles, including the nucleus, and
become small, biconcave discs optimized for oxygen transport. They are released into the bloodstream
and circulate throughout the body.

• Maturation is characterized by
• Reduction in cell size
• Increase in the amount of hemoglobin
• Disappearance of nucleus
 • Change in staining characteristics of cytoplasm (basophilic to eosinophilic) due to fall in content of RNA.

Control of Erythropoiesis
Nutritional Factors
• Proteins
• Glycine and succinyl CoA: for haem synthesis
• Other amino acids: for globin synthesis

• Vitamins
• Vitamin B6: for haem synthesis
• Vitamin B12 and folic acid: for red cell maturation
• Vitamin C: for intestinal absorption of iron (Fe2+)
• Minerals
• Fe2+ and Cu2+: for heme synthesis
• Cobalt salts: as constituent of vitamin B12.

Deficiencies
• Iron-Deficiency Anemia
• Cause: Inadequate dietary intake of iron, impaired absorption, or increased demand for iron (e.g.,
during pregnancy or growth spurts).
• Characteristics: Microcytic (smaller than normal) and hypochromic (paler than normal) red blood
cells.
• Vitamin B12 Deficiency Anemia
• Cause: Inadequate dietary intake, malabsorption issues (vegetarians), or pernicious anemia
(autoimmune destruction of intrinsic factor needed for B12 absorption, after removal of stomach,
Addisonian anemia).
• Characteristics: megaloblastic macrocytic (larger than normal) red blood cells, neurological
symptoms in addition to anemia.
• Folic Acid Deficiency Anemia
• Cause: Inadequate dietary intake, malabsorption issues, or increased demand (e.g., during pregnancy).
• Characteristics: Similar to vitamin B12 deficiency anemia, with macrocytic red blood cells.
Factors Influencing Bone Marrow Activity
Stimulating Factors
• Erythropoietin
• Feedback control of RBC production
• Glycoprotein
• Produced by kidneys 85% (interstitial cells of peritubular capillary), liver 15% (perivenous
hepatocytes)
• Converts committed stem cells to proerythroblasts
• Metabolized by liver
• Stimulated by hypoxia, high altitude, androgens, alkalosis, catecholamines and cobalt salts
• Hormones
• Androgen, LH
• TSH, thyroid hormone
• ACTH, glucocorticoids
• Catecholamines

Inhibiting factors
• Uremia
• Bacterial toxins
• Cytotoxic drugs
• Radiation

Anemia
• Reduction in hemoglobin concentration of the circulating blood below the normal for that age and sex of the
individual.

Causes
1. Impaired Red Cell Formation
• Folic acid deficiency: during periods of rapid growth, e.g., pregnancy and growing child
• Vitamin B12 deficiency – also affect nervous system (tingling of hand tips and toes)
• In vegetarians
• After removal of stomach
• Gastric atrophy (pernicious anemia or Addisonian anemia)
• Vitamin C deficiency: iron is absorbed more readily in ferrous state. Vitamin C converts ferric to ferrous
iron.

2. Due to Lack of Stimulating Factor (Erythropoietin)

• Chronic renal failure

3. Due to bone marrow depression

• Uremia
• Bacterial toxins
• Drugs (chloramphenicol)
• Cytotoxic drugs
• Radiation

4. Due to infiltration of marrow by other cells

• Tumor, leukemia

Increased Red Cell Destruction

• Sickle Cell Anemia
• Cause: Genetic mutation leading to the production of abnormal hemoglobin (HbS).
• Characteristics: Sickled-shaped RBCs, increased susceptibility to hemolysis, and blockages in blood
vessels.
• Thalassemia
• Causes: Genetic mutations affecting the synthesis of hemoglobin.
• Characteristics: Reduced production of one or more globin chains, leading to ineffective erythropoiesis
and hemolysis.
• Autoimmune Hemolytic Anemia
• Cause: The immune system mistakenly recognizes its own RBCs as foreign and attacks them.
• Characteristics: Coombs test positivity, increased destruction of RBCs, and the presence of
autoantibodies.
• Drug-Induced Hemolytic Anemia
• Cause: Certain medications can induce an immune response, leading to hemolysis.
• Characteristics: Presence of drug-induced antibodies, increased destruction of RBCs.
• Infections
• Malaria
• Cause: Infection by Plasmodium parasites leading to the destruction of RBCs.
• Characteristics: Cyclic fevers, anemia during active infection.
• Mechanical Trauma
• Microangiopathic Hemolytic Anemia (MAHA):
• Cause: Conditions causing damage to RBCs as they pass through small blood vessels.
• Characteristics: Schistocytes (fragmented RBCs) in the peripheral blood, associated with conditions like
thrombotic thrombocytopenic purpura (TTP) or disseminated intravascular coagulation (DIC).
• Enzyme Deficiencies
• Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency:
• Cause: Genetic deficiency of the G6PD enzyme, making RBCs vulnerable to oxidative stress.
• Characteristics: Hemolysis triggered by certain drugs or infections.
• Toxins and Chemicals
• Lead Poisoning:
• Cause: Exposure to lead can impair RBC production and increase their susceptibility to hemolysis.
• Characteristics: Anemia, basophilic stippling of RBCs, lead lines on X-rays.
• Characteristics
• Jaundice: Increased bilirubin levels due to the breakdown of RBCs.
• Splenomegaly: Enlarged spleen as it actively removes damaged RBCs.
• Reticulocytosis: Increased levels of reticulocytes (immature RBCs) in response to the accelerated
destruction.
Blood Loss
Hemorrhage, blood during child birth

Hemoglobin

• Structure of Hemoglobin
• Hemoglobin is a complex protein molecule composed of four subunits, each containing an iron-
containing heme group. The heme group is crucial for the binding and transport of oxygen. There are
two main types of hemoglobin subunits, known as globins:
• Alpha (α) Globin Chains
▪ Two alpha globin chains make up one-half of the hemoglobin molecule.
• Beta (β) Globin Chains
▪ Two beta globin chains make up the other half of the hemoglobin molecule.
• Function of Hemoglobin
• The primary function of hemoglobin is to transport oxygen from the lungs to the tissues and organs,
and to carry carbon dioxide, a waste product, from the tissues back to the lungs for exhalation. The
oxygen-binding ability of hemoglobin is due to the iron atoms within the heme groups.
• Oxygen Binding and Release
• In the lungs, where oxygen levels are high, hemoglobin binds to oxygen, forming oxyhemoglobin. This
process is facilitated by the iron ions in the heme groups.
• In the tissues, where oxygen levels are lower, oxyhemoglobin releases oxygen to the cells. This ability to
bind and release oxygen is crucial for efficient gas exchange.
• Carbon Dioxide Transport
• Hemoglobin also plays a role in carrying carbon dioxide. Carbon dioxide is transported in the blood in
various forms, one of which is as carbaminohemoglobin.
• Carbon dioxide binds to specific amino acids on the globin chains, helping to transport it back to the
lungs for elimination.
• Buffering Effect
• Hemoglobin acts as a buffer, helping to maintain the pH of the blood. The binding and release of oxygen
influence the acidity (pH) of hemoglobin, allowing it to act as a buffer against changes in blood pH.
Types of Hemoglobin
Physiologic Types
• Hemoglobin A (HbA)
• Composition: Two alpha (α) and two beta (β) globin chains.
• Function: The predominant adult hemoglobin responsible for oxygen transport.
• Percentage in Adults: About 95-98% of total hemoglobin in healthy adults.
• Hemoglobin A2 (HbA2)
• Composition: Two alpha (α) and two delta (δ) globin chains.
• Function: A minor adult hemoglobin variant.
• Percentage in Adults: Normally about 2-3% of total hemoglobin.
• Hemoglobin F (HbF or Fetal Hemoglobin)
• Composition: Two alpha (α) and two gamma (γ) globin chains.
• Function: The predominant hemoglobin in fetal life, facilitating oxygen transfer across the placenta.
• Percentage in Adults: Usually less than 1% of total hemoglobin in healthy adults.

Pathologic types
• Hemoglobin S (HbS)
• Pathology: Results from a point mutation in the beta-globin gene, leading to the substitution of glutamic
acid with valine.
• Sickle Cell Anemia: Individuals with two copies of the HbS gene (HbSS) exhibit sickle cell anemia,
characterized by the presence of sickle-shaped red blood cells that can cause vascular occlusion and
other complications.
• Methemoglobin (MetHb)
• Pathology: Occurs when iron in heme is in the ferric state (Fe3+) instead of the normal ferrous state
(Fe2+).
• Clinical Significance: Methemoglobin does not bind oxygen effectively, leading to tissue hypoxia.
Methemoglobinemia can be acquired or hereditary.
• Hemoglobin A1c
• Hemoglobin A1c (HbA1c), also known as glycated hemoglobin, is a laboratory test commonly used to
assess the average blood glucose levels over the past two to three months. This test is particularly
valuable in managing and monitoring diabetes.
• Formation of Hemoglobin A1c:
• Normal Glycation Process:
▪ When blood glucose levels are elevated, glucose molecules can bind to hemoglobin in red blood cells
through a process known as glycation.
• Stable Complex:
▪ The glucose-hemoglobin complex (HbA1c) is stable and remains in the red blood cells for the
lifespan of these cells, which is typically around 120 days.
• Proportional to Average Blood Glucose Levels:
▪ The percentage of HbA1c reflects the average blood glucose concentration during the lifespan of red
blood cells. Higher blood glucose levels result in a higher percentage of glycated hemoglobin.
• Clinical Significance
• Diabetes Management: HbA1c is a crucial tool for managing diabetes by providing an indication of long-
term glycemic control.
Breakdown of RBCs

• Senescence of Red Blood Cells (RBCs)

• RBCs have a finite lifespan, approximately 120 days. As they age, changes occur in their membrane
structure, making them more fragile.
• Removal from Circulation
• Aged or damaged RBCs are recognized and phagocytosed (engulfed) primarily by macrophages in the
spleen. Some removal also occurs in the liver and bone marrow.
• Hemolysis within Macrophages
• Once engulfed, RBCs are broken down within the phagocytic macrophages.
• Hemoglobin Release
• Hemoglobin, the oxygen-carrying protein in RBCs, is released from the breakdown of the cell.
• Heme Breakdown
• Heme, the iron-containing component of hemoglobin, is enzymatically broken down by heme
oxygenase.
• Heme is converted into biliverdin, releasing iron.
• Biliverdin to Bilirubin Conversion
• Biliverdin is then converted into bilirubin by the enzyme biliverdin reductase.
• Unconjugated Bilirubin
• Bilirubin released from heme breakdown is unconjugated, meaning it is not water-soluble.
• Transport to the Liver
• Unconjugated bilirubin is transported to the liver, mainly bound to albumin in the blood.
• Conjugation in the Liver
• In the liver, bilirubin is conjugated (modified) by the addition of glucuronic acid, making it water-
soluble.
• Conjugated bilirubin is then excreted into the bile.
• Bile Secretion
• Conjugated bilirubin is part of the bile secreted by the liver. Bile helps in the digestion and absorption of
fats in the small intestine.
• Intestinal Bacterial Action
• In the intestine, bilirubin undergoes further modifications through bacterial action, forming
urobilinogen.
• Fecal Excretion
• Urobilinogen contributes to the color of feces. Some urobilinogen is reabsorbed into the bloodstream,
while the rest is excreted in the feces.
• Renal Excretion
• A small amount of urobilinogen is filtered by the kidneys and excreted in the urine, contributing to its
yellow color.

Jaundice
• Jaundice, also known as icterus, is a medical condition characterized by yellowing of the skin, mucous
membranes, and the whites of the eyes. This yellow discoloration is caused by elevated levels of bilirubin, a
yellow pigment produced during the breakdown of red blood cells.
• Prehepatic Jaundice (Hemolytic Jaundice)
• Cause: Increased breakdown of red blood cells (hemolysis), leading to an elevated level of
unconjugated bilirubin.
• Characteristics: High levels of unconjugated bilirubin; the liver is capable of processing the increased
bilirubin load.
• Hepatic Jaundice (Hepatocellular Jaundice)
• Cause: Liver dysfunction or damage, impairing the uptake, conjugation, or excretion of bilirubin.
 • Characteristics: Elevated levels of both unconjugated and conjugated bilirubin; liver function tests may
reveal abnormalities.
• Posthepatic Jaundice (Obstructive Jaundice or Surgical Jaundice)
• Cause: Obstruction of the bile ducts, preventing the normal flow of bile and leading to the accumulation
of conjugated bilirubin in the bloodstream.
• Characteristics: Elevated levels of conjugated bilirubin; pale-colored stools, dark urine; liver function
tests may show abnormalities.

Physiologic Jaundice
• Physiologic jaundice, also known as neonatal jaundice, is a common condition in newborns characterized
by the yellowing of the skin and eyes. It typically occurs in the first week of life and is often considered a
normal and transient phenomenon. Physiologic jaundice results from an accumulation of bilirubin, a yellow
pigment produced during the breakdown of red blood cells, and is usually benign.
• Immaturity of the Liver
• The liver plays a crucial role in processing and excreting bilirubin. In newborns, the liver is not fully
mature, and its ability to process bilirubin may be limited.
• Delayed Excretion
• The excretion of bilirubin into the bile and its elimination from the body may be slower in newborns,
contributing to higher bilirubin levels.
• Breastfeeding and Fasting
• Breastfeeding jaundice can occur in some infants due to insufficient intake of breast milk, leading to
dehydration and increased bilirubin levels.
• Breast milk jaundice may also occur due to certain substances in breast milk that can inhibit bilirubin
excretion.
• Peak Occurrence
• Physiologic jaundice typically peaks around the third to fourth day of life.
• Benign Nature
• Physiologic jaundice is generally a benign and self-limiting condition.
• Management
• Monitoring: Bilirubin levels are often monitored to ensure they do not reach levels that could be
harmful.
• Phototherapy: In some cases, exposure to special blue lights (phototherapy) may be used to help break
down excess bilirubin in the skin.
• Resolution
• Physiologic jaundice typically resolves on its own as the baby's liver matures and bilirubin metabolism
improves.
• Differentiation from Pathologic Jaundice
• Physiologic jaundice should be differentiated from pathologic jaundice, which may be indicative of
underlying medical conditions such as hemolytic disorders, infections, or metabolic disorders.
• Importance of Monitoring
• Regular monitoring of bilirubin levels is essential to ensure that jaundice does not reach levels that
could lead to kernicterus, a rare but serious condition characterized by the deposition of bilirubin in the
brain.

Packed Cell Volume or Hematocrit (PCV)

• Packed Cell Volume (PCV), also known as hematocrit, is a blood test that measures the proportion of blood
that is cellular components, primarily red blood cells (RBCs), compared to the total volume of blood. The
PCV is expressed as a percentage. This test is valuable in assessing the concentration of red blood cells in
the blood and is commonly used in various medical contexts.
• Procedure for Measuring Packed Cell Volume
• Blood Collection
▪ A blood sample is usually collected from a vein, most commonly from the arm.
• Centrifugation
▪ The blood sample is placed in a tube and subjected to centrifugation, a process that separates its
components based on their densities.
• Formation of Layers
▪ As a result of centrifugation, the blood components separate into three layers: plasma at the top
(straw-colored), thin layer of white blood cells and platelets in the middle (buffy coat), red blood
cells at the bottom.
• Measurement
▪ The height of the column of red blood cells is measured against the total height of the column
(including plasma).
• Calculation
• The PCV is calculated as the percentage of the total volume that is occupied by red blood cells.
• Significance of Packed Cell Volume
• Indication of Anemia
▪ PCV is often used to assess the severity of anemia. A lower PCV indicates a lower concentration of
red blood cells, which can be indicative of conditions such as iron deficiency anemia or vitamin B12
deficiency.
• Monitoring Blood Disorders
▪ PCV is part of a complete blood count (CBC), a routine blood test that provides information about
various blood components. Changes in PCV can help monitor conditions affecting blood cells.
• Dehydration
▪ In cases of dehydration, where there is a reduction in plasma volume, the PCV may appear elevated
due to the relative increase in the concentration of red blood cells.
 • Polycythemia
▪ An elevated PCV may be observed in conditions such as polycythemia vera, where there is an
excessive production of red blood cells.

Erythrocyte Sedimentation Rate

• The erythrocyte sedimentation rate (ESR) is a blood test that measures the rate at which red blood cells
(erythrocytes) settle at the bottom of a tube as a pile of aggregates (rouleaux) over a specified period. This
test is a nonspecific marker of inflammation and is only used as prognostic tool rather than diagnosis.
• Procedure for Erythrocyte Sedimentation Rate
• Blood Collection:
▪ A blood sample is usually collected from a vein, typically in the arm.
• Anti-Coagulation
▪ The blood is mixed with an anticoagulant to prevent clotting.
• Vertical Tube
▪ The blood is then placed in a vertical tube, and the rate at which red blood cells settle is measured.
• Gravity and Aggregation
▪ In the absence of external forces, red blood cells tend to settle due to gravity.
▪ During inflammation, proteins in the blood can cause red blood cells to stick together, increasing
the rate of sedimentation.
• Measurement
• The result is reported in millimeters per hour (mm/hr) and indicates the distance the red blood cells
have descended in the tube over the specified time.
• Interpretation of Erythrocyte Sedimentation Rate:
• Normal Range
▪ The normal range for ESR can vary based on age and sex. In general, the reference range for adults
is 0-20 mm/hr for males and 0-30 mm/hr for females.
• Increased ESR
▪ An elevated ESR is often associated with inflammatory or infectious conditions. This can include
conditions such as infections, autoimmune diseases, and certain types of arthritis.
• Non-Specific Marker
▪ ESR is a nonspecific marker, meaning it can be elevated in a variety of conditions, and a high ESR
does not pinpoint a specific diagnosis.
• Monitoring Treatment
▪ ESR can be used to monitor the response to treatment in inflammatory conditions. A decreasing ESR
may indicate a positive response to therapy.
• Factors affecting ESR
• Surface area of falling RBC (inversely related)
• Composition of plasma proteins: fibrinogen (pregnancy), alpha-2 and gamma globulins (infections)
increase ESR
• Viscosity of medium: inversely related
• Red cell count: inversely related
• Size and shape of RBC: ESR in low in sickle cell anemia and congenital spherocytosis
• Physiologic Variations
• Physiologic variations: female>male, menstruation, pregnancy, old age
• Pathologic Variations
• Anemia
• Infections
• Any wasting and diseases with tissue destruction (e.g., cancer)
Red Cell Indices
• Mean Corpuscular Volume (MCV)
• Definition: MCV represents the average volume or size of a single red blood cell.
• Calculation: MCV is calculated by dividing the total volume of packed red blood cells by the total
number of red blood cells.
• Units: MCV is typically expressed in femtoliters (fL) or cubic micrometers (μm³).
• >95 fl: macrocytes, <80fl: microcytes
• Interpretation:
▪ Microcytic Anemia: Low MCV (small cells), seen in conditions like iron deficiency anemia.
▪ Normocytic Anemia: Normal MCV, seen in conditions like anemia of chronic disease.
▪ Macrocytic Anemia: High MCV (large cells), seen in conditions like vitamin B12 or folate deficiency.
• Mean Corpuscular Hemoglobin (MCH)
• Definition: MCH represents the average amount of hemoglobin in a single red blood cell.
• Calculation: MCH is calculated by dividing the total amount of hemoglobin by the total number of red
blood cells.
• Units: MCH is typically expressed in picograms (pg).
• Interpretation:
▪ Hypochromic Anemia: Low MCH (less hemoglobin per cell), seen in conditions like iron deficiency
anemia.
▪ Normochromic Anemia: Normal MCH, seen in various anemias.
▪ Hyperchromic: The term is rarely used, and conditions causing high MCH are uncommon.
• Mean Corpuscular Hemoglobin Concentration (MCHC)
• Definition: MCHC represents the concentration of hemoglobin in a single red blood cell.
• Calculation: MCHC is calculated by dividing the total amount of hemoglobin by the total volume of
packed red blood cells and multiplying by 100.
• Units: MCHC is typically expressed as a percentage.
• Interpretation:
▪ Hypochromic Anemia: Low MCHC (less concentrated hemoglobin), seen in conditions like iron
deficiency anemia.
▪ Normochromic Anemia: Normal MCHC, seen in various anemias.
▪ Hyperchromic: The term is rarely used, and conditions causing high MCHC are uncommon.
• Mean Cell Diameter (MCD)

Disorders of Red Blood Cells

Anemia (referred above)

Sickle Cell Disease

Sickle Cell Disease (SCD) is a genetic disorder characterized by the presence of abnormal hemoglobin, known as
hemoglobin S (HbS). This inherited condition affects the structure and function of red blood cells (RBCs),
leading to various complications.
• Genetics
• Sickle Cell Disease is inherited in an autosomal recessive manner. Individuals with two copies of the
abnormal gene (HbS/HbS) have the disease, while carriers with one abnormal gene and one normal
gene (HbS/HbA) are said to have sickle cell trait.
• Hemoglobin S (HbS)
• In individuals with SCD, a point mutation in the beta-globin gene results in the production of abnormal
hemoglobin S. When deoxygenated, HbS molecules can polymerize and cause RBCs to take on a
characteristic sickle shape.
• Sickled Red Blood Cells
• The sickle-shaped RBCs are less flexible and prone to clumping together. This can lead to vaso-occlusive
crises, where blood vessels become blocked, causing pain and tissue damage.
• Symptoms and Complications
• Common symptoms include chronic anemia, fatigue, and jaundice.
• Complications include vaso-occlusive crises, acute chest syndrome, stroke, and organ damage due to
reduced blood flow.
• Vaso-Occlusive Crises
• Episodes of severe pain occur when sickled RBCs block blood vessels, leading to ischemia and tissue
damage. Triggering factors include dehydration, infections, and stress.
• Acute Chest Syndrome
• A serious complication involving inflammation and blockage of small blood vessels in the lungs. It can
lead to respiratory distress and is a medical emergency.

Thalassemia
• Thalassemia is a group of inherited blood disorders characterized by reduced or absent production of one
of the globin chains of hemoglobin. Hemoglobin is the protein in red blood cells responsible for carrying
oxygen throughout the body. The severity of thalassemia can vary, and the condition is classified into two
main types: alpha thalassemia and beta thalassemia.
• Alpha Thalassemia
• Cause: Alpha thalassemia is caused by mutations in the genes responsible for the synthesis of alpha-
globin chains.
• Severity:
▪ Silent Carrier: One gene affected; usually asymptomatic.
▪ Alpha Thalassemia Trait: Two genes affected; mild anemia.
▪ Hemoglobin H Disease: Three genes affected; moderate to severe anemia.
▪ Hydrops Fetalis: All four genes affected; usually incompatible with life.
• Beta Thalassemia
• Cause: Beta thalassemia is caused by mutations in the genes responsible for the synthesis of beta-globin
chains.
• Severity:
▪ Beta Thalassemia Minor (Trait): One gene affected; mild anemia.
▪ Beta Thalassemia Intermedia: Two genes affected; moderate anemia.
▪ Beta Thalassemia Major (Cooley's Anemia): Two genes affected; severe anemia requiring regular
blood transfusions.
• Clinical Features
• Anemia: Reduced hemoglobin leads to anemia, causing fatigue, weakness, and pale skin.
• Enlarged Spleen: The spleen may become enlarged due to the destruction of abnormal red blood cells.
• Bone Deformities: In severe cases, bone marrow expansion can cause facial and skull deformities.
• Growth and Development Issues: Children with thalassemia may experience delayed growth and
development
• Treatment
• Blood Transfusions: Regular transfusions are often required for individuals with moderate to severe
thalassemia.
• Chelation Therapy: To manage iron overload resulting from frequent transfusions.
 • Bone Marrow Transplant: A potential curative option for some individuals, particularly in severe cases.

Hereditary Spherocytosis
• Hereditary Spherocytosis (HS) is a genetic disorder that affects red blood cells (RBCs), leading to their
spherical shape instead of the normal biconcave disc shape. This inherited condition results from mutations
in genes encoding proteins involved in the structure and function of the RBC membrane.
• Genetics
• HS is primarily inherited in an autosomal dominant manner, meaning an affected individual has a 50%
chance of passing the condition to each offspring.
• Pathophysiology
• Mutations affect genes encoding proteins such as spectrin, ankyrin, band 3, and other membrane
proteins.
• Loss of structural components leads to decreased membrane stability, causing RBCs to become
spherical and less flexible.
• Clinical Features
• Anemia: Due to the premature destruction (hemolysis) of spherocytic RBCs in the spleen.
• Jaundice: Increased bilirubin levels resulting from RBC breakdown.
• Splenomegaly: Enlargement of the spleen as it works to remove abnormal RBCs.
• Diagnosis
• Blood Tests: Peripheral blood smear reveals spherocytic RBCs, increased reticulocyte count, and
indirect hyperbilirubinemia.
• Osmotic Fragility Test: RBCs are more fragile in a hypotonic solution.
• Treatment
• Folate Supplementation: Helps support RBC production.
• Blood Transfusions: In severe cases or during crises.
• Splenectomy: Often curative, as it removes the primary site of RBC destruction. However, it increases
the risk of infections, especially with encapsulated bacteria.
• Complications
• Gallstones: Increased bilirubin levels may lead to the formation of gallstones.
• Aplastic Crisis: Transient cessation of RBC production, often triggered by infections such as parvovirus
B19.
• Management
• Regular Follow-Up: Monitoring of hemoglobin levels, bilirubin levels, and overall health.
• Vaccinations: Especially important before splenectomy to prevent infections.
• Genetic Counseling
• Individuals with HS or a family history of the condition may benefit from genetic counseling to
understand the inheritance pattern and assess the risk of passing the disorder to offspring.

G6PD Deficiency
• Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is an inherited genetic disorder affecting red blood
cells (RBCs). G6PD is an enzyme crucial for protecting RBCs from oxidative damage. Deficiency in G6PD
leads to vulnerability to oxidative stress, resulting in hemolysis (destruction of RBCs).
• Genetics
• G6PD deficiency is inherited in an X-linked recessive manner, primarily affecting males. Females can be
carriers or, in rare cases, manifest symptoms if they inherit two affected X chromosomes.
• Pathophysiology
• G6PD is essential for maintaining the reduced form of glutathione, an antioxidant protecting RBCs from
oxidative stress.
 • G6PD deficiency leads to decreased protection against oxidative damage, making RBCs more
susceptible to hemolysis.
• Triggers of Hemolysis
• Infections: Certain infections, especially those causing fever, can trigger hemolysis.
• Certain Foods and Medications: Fava beans and certain medications, such as certain antimalarial drugs
and sulfa drugs, can induce hemolysis.
• Oxidative Stress: Exposure to oxidative stressors, including certain chemicals and foods, can lead to
hemolysis.
• Clinical Features
• Hemolysis: Presents as jaundice, dark urine, and anemia during episodes of oxidative stress.
• Favism: Acute hemolysis triggered by consuming fava beans.
• Neonatal Jaundice: Newborns with G6PD deficiency may experience jaundice, especially under
conditions of stress.

Polycythemia Vera
• Polycythemia vera (PV) is a rare and chronic blood disorder characterized by the overproduction of red
blood cells (erythrocytosis) in the bone marrow. This condition is classified as a myeloproliferative
neoplasm, a group of disorders involving abnormal proliferation of blood cells.
• Pathophysiology
• PV results from a mutation in the JAK2 gene, leading to the overactivation of the JAK-STAT signaling
pathway.
• The abnormal signaling promotes the excessive production of red blood cells in the bone marrow.
• Clinical Features
• Erythrocytosis: Elevated red blood cell count, hemoglobin, and hematocrit.
• Hyperviscosity: Increased blood thickness, potentially leading to complications such as thrombosis.
• Splenomegaly: Enlargement of the spleen due to increased blood cell production.
• Itching (Pruritus): Particularly after exposure to warm water, attributed to histamine release.
• Thrombosis: Increased risk of blood clot formation, which can lead to serious complications.
• Diagnosis
• Complete Blood Count (CBC): Elevated red blood cell count, hemoglobin, and hematocrit.
• JAK2 Mutation Testing: Identification of the JAK2 V617F mutation in the blood.
• Bone Marrow Biopsy: To confirm increased cellularity and rule out other conditions.
• Treatment
• Phlebotomy: Regular removal of blood to reduce the elevated red blood cell count.
• Medications:
▪ Hydroxyurea: Suppresses bone marrow activity and reduces blood cell production.
▪ Aspirin: To prevent thrombotic complications.
▪ JAK Inhibitors: Some patients may benefit from drugs that target the abnormal JAK-STAT signaling
pathway.
• Complications
• Thrombosis: Can lead to stroke, heart attack, or other organ damage.
• Myelofibrosis: Scarring of the bone marrow, a potential progression of PV.
• Transformation to acute leukemia: rare