XXIX.
NONMALIGNANT LEUKOCYTE DISORDER
QUALITATIVE DISORDERS OF LEUKOCYTES
Morphological Abnormalities with and without
Functional Defects
1. Pelger-Hut Anomaly (PHA)
aka true or congenital PHA
an autosomal dominant disorder characterized
by decreased nuclear segmentation (bilobed,
unilobed) and a characteristic coarse chromatin
clumping pattern potentially affecting all
leukocytes, although morphologic changes are
most obvious in mature neutrophils
1 in 4785 in the United States
a result of a mutation in the lamin -receptor
gene
- an inner nuclear membrane protein that
combines -type lamins and heterochromatin
- plays a major role in leukocyte nuclear shape
changes that occur during normal maturation
round, ovoid or peanut-shaped nuclei
bilobed forms
- the characteristic spectacle-like (pince-nez)
morphology with the nuclei attached by a thin
filament
Homozygous PHA
- all neutrophils are affected
- round nuclei
Heterozygous PHA
- 55% to 93% of the neutrophil population are
affected
- mixture of all of the aforementioned nuclear
shapes
Neutrophils function normally.
2. Pseudo- or Acquired Pelger-Hut Anomaly
observed in patients with:
- myelodysplastic syndromes (MDS)
- acute myeloid leukemia
- chronic myeloproliferative neoplasms
- HIV infections
- tuberculosis
1 of 13
- Mycoplasma pneumoniae
- severe bacterial infections
Drugs known to induce pseudo-PHA:
- mycophenolate mofetil
- valproate
- sulfisoxazole
- ganciclovir
- ibuprofen
- paclitaxel
- docetaxel
Differentiating true PHA and pseudo-PHA:
(1) number of cells present with PHA morphology
- true PHA > pseudo-PHA (63% to 93% vs
<38%)
(2) In true PHA, all WBC lineages are potentially
affected in terms of nuclear shape and chromatin
structure.
(3) In pseudo-PHA the phenomenon is usually seen
only in neutrophils, except for some cases of
MDS where monocytes, eosinophils, and
basophils may exhibit PHA morphology.
(4) If true PHA is suspected, a careful examination
of peripheral blood smears of family members
may reveal similar findings.
(5) Hypogranular neutrophils are a common finding
in MDS-related pseudo-PHA. In true PHA,
neutrophils exhibit normal granulation.
3. Neutrophil Hypersegmentation
>5 lobes
most often associated with the megaloblastic
anemias
can be seen in the myelodysplastic syndromes
and represent a form of myeloid dysplasia
found (less frequently) in hereditary neutrophil
hypersegmentation
Myelokathexis
- a rare hereditary condition characterized by
normal granulocyte production; however,
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER 2 of 13

there is impaired release into circulation that 4. Alder-Reilly Anomaly

leads to neutropenia transmitted as recessive trait
- neutrophils appear hypermature characterized by granulocytes with large, darkly
- There may be staining metachromatic cytoplasmic granules
hypersegmentation (Alder-Reilly bodies or Reilly bodies) composed
primarily of partially digested
hypercondensed chromatin
mucopolysaccharides
pyknotic changes
morphology may resemble heavy toxic
- component of an extremely rare inherited granulation
disorder called WHIM

3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
Neutrophilia, Dhle bodies, and left shift are
NOT seen
In some patients, granules are found in
lymphocytes and monocytes
incomplete degradation of mucopolysaccharide
Reilly bodies are most commonly associated
with:
- Hurler syndrome
- Hunter syndrome
- Maroteaux-Lamy polydystrophic dwarfism
Leukocyte function is NOT affected
5. Chdiak-Higashi Syndrome
a rare, fatal, autosomal recessive disease
characterized by abnormal fusion of granules in
most cells that contain granules throughout the
body
fused granules are large and mostly
dysfunctional
Hematopoietic cells are affected
giant lysosomal granules in granulocytes,
monocytes, and lymphocytes
Patients often have bleeding issues due to
abnormal dense granules in platelets,
associated with a mutation in the CHS1 LYSt
gene on chromosome 1q42.1-2 that encodes for
a protein involved in vesicle fusion or fission
6. May-Hegglin Anomaly
a rare, autosomal dominant platelet disorder
variable thrombocytopenia
giant platelets
large Dhle body-like inclusion (composed of
precipitated myosin heavy chains) in
neutrophils, eosinophils, basophils, and
monocytes
caused by the mutation in the MYH9 gene on
chromosome 22q12-13
disordered production of myosin heavy chain
type IIA which affects megakaryocyte
maturation and platelet fragmentation
3 of 13
patients are asymptomatic, but few have mild
bleeding tendencies that are related to the
degree of thrombocytopenia
Normal Morphology with Functional Abnormalities
1. Chronic Granulomatous Disease
a rare inherited disorder caused by the
decreased ability of phagocytes to produce
superoxide and reactive oxygen species
The basic defect is one or more mutations in
genes responsible for proteins that make up a
complex known as NADPH oxidase.
heterogeneous
Most patients experience bacterial and fungal
infections of the lung, skin, lymph nodes, and
liver.
Macrophage-rich granulomas can be found in
liver, spleen, and other organs.
2. Leuokocyte Adhesion Disorders (LADs)
rare autosomal recessive inherited disorders
inability of neutrophils and monocytes to adhere
to endothelial cells and to transmigrate from the
blood to the tissues
increased and potentially lethal bacterial
infections
The basic defect is a mutation in the genes
responsible for the formation of cell adhesion
molecules.
a. LAD I
mutation in exons 5 to 9 in the gene(s)
responsible for 2 integrin subunits,
resulting in either a decreased or
truncated form of the 2 integrin, which is
necessary for adhesion to endothelial
cells, recognition of bacteria, and outside-
in signaling
Patients frequently have neutrophilia,
lymphadenopathy, splenomegaly, and skin
lesions.
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
b. LAD II
rarer than LAD I
leukocytes have normal 2 integrins
molecular defects in SLC35C1, which
codes for a fucose transporter that moves
the fucose from the endoplasmic reticulum
to the Golgi region
Fucose
- needed for posttranslational
fucosylation of glycoconjugates, which
is required for synthesis of selectin
ligans
Patients have growth retardations, a
coarse face, and other physical
deformities.
the defective fucose transporter leads to
an inability to produce functional selectin
ligands and defective leukocyte
recruitment, which leads to recurring
infections
Other clinical findings related to defective
fucose transport are absence of blood
group H antigen, growth retardation, and
neurological defects.
c. LAD III
very rare autosomal recessive disease
leukocytes and platelets have normal
expression of integrins, but there is failure
in response to external signals that would
normally result in leukocyte activation
mutation in Kindlin-3
- Kindlin-3 along with talin are required
for activation of integrin and leukocyte
rolling
Patients experience a mild LAD I-like
immunodeficiency with recurrent bacterial
and fungal infections
decreased platelet integrin GPIIb3,
resulting in bleeding similar to what is
seen in Glanzmann thrombasthenia
4 of 13
3. Miscellaneous Granulocyte Disorders
Myeloperoxidase Deficiency
- deficiency in myeloperoxidase (stimulates
production of hypochlorite and hypochlorous
acid) in the primary granules of neutrophils
and lysosomes of monocytes
- inherited in an autosomal dominant manner
- The defect originates through mutation in the
MPO gene on chromosome 17.
- can be detected by the Siemens Advia
analyzer, which uses myeloperoxidase to
identify cells in the automated differential
Monocyte/Macrophage Lysosomal Storage Disease
1. Mucopolysaccharidoses (MPSs)
family of inherited disorders of GAG degradation
each one is caused by deficient activity of an
enzyme necessary for the degradation of
dermatan sulfate, heparan sulfate, keratan
sulfate, and/or chondroitin sulfate
could result to physical abnormality and mental
retardation
peripheral blood of patient may appear relatively
normal
metachromatic Reilly bodies may be seen in
neutrophils, monocytes, and lymphocytes
Bone marrow may reveal macrophages with
large amounts of metachromatic material.
2. Lipid storage diseases
inherited disorders in which lipid catabolism is
defective
a. Gaucher disease
most common of the lysosomal lipid
storage diseases
an autosomal recessive disorder caused
by a defect or deficiency in the catabolic
enzyme -glucocerebrosidase (gene
located at 1q21), which is necessary for
glycolipid metabolism
accumulation of unmetabolized substrate
sphingolipid glucocerebrosidase in
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
macrophages throughout the body,
including osteoclasts in bone and microglia
in the brain
Clinical triad used in diagnosis:
- hepatomegaly
- Gaucher cells in the bone marrow
- increase in serum phosphatase
heterogeneous
Hematologic features:
- anemia
- thrombocytopenia
- bone marrow contains Gaucher cells
(distinctive macrophages occurring
individually or in clusters) that have an
abundant fibrillar blue-gray cytoplasm
with a striated or wrinkled appearance
Chitotriosidase
5 of 13
- a useful test in determining the level of
glucocerebrosidase in storage
- This biomarker can be used in
diagnosis and monitoring of the
disease.
Periodic acid-Schiff stain
- tests for mucopolysaccharides in
Gaucher cells
Treatment of Gaucher disease includes:
- the use of enzyme replacement therapy
with recombinant glucocerebrosidase
- use of agents that reduce the amount of
the substrate glucocerebrosidase
- Stem cell transplantation
- use of pharmacologic chaperones that
are active site-specific competitive
glucocerebrosidase inhibitors
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER 6 of 13

Pseudo-Gaucher cells
- found in the bone marrow in some
patients with thalassemia, chronic
myelogenous leukemia and acute
lymphoblastic leukemia
- result of excessive cell turnover and
overwhelming the glucocerebrosidase
enzyme rather than a true decrease in
the enzyme
- do NOT contain tubular inclusions

b. Niemann-Pick disease
autosomal recessive disorder
has three subtypes: A, B, and C

Genetic B and T Lymphocyte Abnormalities associated with a microdeletion in chromosome

decreased production of B cells, T cells, or both
1. T lymphocyte abnormality
DiGeorge syndrome
characterized by the absence or
underdevelopment of the thymus and thus
markedly decreased numbers of T lymphocytes
band 22q11.2, which is the most common
chromosome deletion and occurs in
approximately 1 in 3500 births
Patients have defective parathyroid glands,
cardiac abnormalities, abnormal facial

3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER 7 of 13

development, neurologic disorders, and

hypocalcemia.

Complete DiGeorge Syndrome

- athymic patients
- less than 1% of patients have this condition

2. Sex-linked agammaglobulinemia (XLA)

B cell disease
caused by a mutation in the dene encoding
Bruton tyrosine kinase (BTK)
- BTK is important for B cell development,
differentiation, and signaling
decreased production of BTK
3. Combined B lymphocyte/T lymphocyte
abnormalities
A. Severe combined immunodeficiency (SCID)
1) Adenosine deaminase deficiency
excess amounts of adenosine and 2-
deoxyadenosine, which cause
lymphocyte depletion through a
variety of mechanisms
2) X-linked SCID
more common
mutation in the gene encoding the IL-
2 receptor gamma chain, which is
shared by several interleukins

B. Wiskott-Aldrich Syndrome
X-linked
caused by a mutation in a gene that
encodes a protein called WASp
Absence of WASp affects migration,
adhesion, and activation of a variety of
leukocytes, including T cells, B cells, and
NK cells.

3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
QUANTITATIVE ABNORMALITIES OF
LEUKOCYTES
Neutrophils
Neutrophilia
- increase in neutrophils above 7.0 x 109/L in
9
adults and 8.5 x 10 /L in children
Absolute Neutrophil Count (ANC)
- determined by adding the number of
segmented and band neutrophils
Leukemoid reaction
- refers to a reactive leukocytosis above 50 x
9
10 /L with neutrophilia and a marked left shift
- result of acute and chronic infection,
metabolic disease, inflammation, or response
to a malignancy
- may be confused with chronic myelogenous
leukemia
Leukoerythroblastic reaction
- refers to the presence of immature
neutrophils, nucleated RBCs, and teardrop
RBCs in the same sample
- often accompanied by neutrophilia
8 of 13
- point to the possibility of a space-occupying
lesion in the bone marrow
- strongly associated with primary
myelofibrosis
Neutropenia
- decrease in the absolute neutrophil count
9
below 2.0 x 10 /L in white adults and 1.3 x
9
10 /L in black adults
- risk of infection increases as the ANC lowers
- can be classified as:
inherited
acquired (more common)
Agranulocytosis
- refers to neutrophil counts of less than 0.5 x
9
10 /L
Immune-mediated neutropenia
- caused by antibody binding to neutrophil
antigens
Alloimmune Neonatal Neutropenia
- maternal IgG crosses the placenta and binds
to neutrophil-specific antigens inherited from
the father, such as FcRIIIb, NB1, or HLA
- occurs in approximately 1 in 2000 births
- severity varies
- Neutrophil counts rise after a few months,
consistent with the half-life of the maternal
anitbody.
Autoimmune neutropenia in children
- primary illness, with moderate to severe
neutropenia developing as a result of
antibodies to HNA-1
- self-limiting, with resolution of neutrophil
counts after 7 to 24 months
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
Secondary autoimmune neutropenia
- associated with autoimmune disorders such
as rheumatoid arthritis and associated Felty
syndrome, systemic lupus erythematosis, and
Sjogren syndrome
- may be induced by immune complex
deposition, granulopoiesis-inhibiting
cytokines, and splenomegaly
Intrinsic (constitutional/congenital) neutropenia
- relatively rare group of inherited disorders
that usually present at birth
- due to decreased production from marrow
hypoplasia or proliferation defect
- heterogeneous
Shwachman-Diamond syndrome or
Shwachman-Bodian-Diamond syndrome
- autosomal recessive disorder
- marrow failure, pancreatic insufficiency, and
skeletal abnormalities
- Hematologic findings:
intermittent neutropenia
mild normocytic to macrocytic
normochromic anemia and
reticulocytopenia
thrombocytopenia
myelodysplasia and acute myeloid
leukemia (which is a terminal event)
Congenital severe neutropenia (in adults)
- affects women 18 to 35 years of age
- more immature neutrophils than mature
neutrophils (cells are lost during maturation)
- Treatment: G-CSF
Fanconi anemia
- rare autosomal recessive or X-linked
inherited disease
- characterized by variable degrees of bone
marrow failure, peripheral cytopenias, and an
9 of 13
increased risk for hematologic malignancies
and other cancers
Dyskeratosis congenita
- sex-linked recessive, autosomal dominant or
autosomal recessively inherited disorder
- heterogeneous
- Patients have mucocutaneous abnormalities,
abnormal skin pigmentation, nail dystrophy,
leukoplakia, bone marrow failure, and
increased risk for malignancy.
Eosinophils
Factors that influence the number of eosinophils
in circulation:
- bone marrow proliferation rate and release
into the bloodstream
- movement from the blood into the
extravascular tissues
- cell survival/destruction once the eosinophils
have moved into the tissues
Major function: degranulation (where
substances are released that damage an
offending organism [i.e. parasites] or target cell)
Eosinophilia
- absolute eosinophil count above 0.4 x 109/L
- Nonmalignant causes of eosinophilia are
generally a result of cytokine stimulation,
especially from interleukin-3 and interleukin-
5.
- In underdeveloped countries, increased
peripheral blood eosinophils are seen in
patients with parasite infections, especially
helminthes and protozoa.
- In developed countries, it is associated with
allergic conditions, including asthma, hay
fever, urticarial, and atopic dermatitis.
- It is also seen in scarlet fever, HIV, fungal
infections, autoimmune disorders, and
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
hypersensitivity to antibiotics and antiseizure
medications
Reactive eosinophilia
- abnormality in cytokine regulation and
expression in some neoplasms
- seen in acute lymphoblastic leukemia,
subtype t(5;14)
Hypereosinophilic syndrome (HES)
- eosinophilia (> 1.5 x 109/L) lasting more than
6 months without an identifiable cause
- considered to be myeloproliferative neoplasm
Eosinopenia
- absolute eosinophilic count of less than 0.09
9 - absolute monocyte count of less than 0.2 x
x 10 /L
- most often associated with conditions that
result in marrow hypoplasia, specifically
involving leukocytes, and infection or
inflammation that is accompanied by
neutrophilia
- Absolute eosinopenia has been reported in
autoimmune disorders, steroid therapy,
stress, sepsis, and acute inflammatory states.
Basophils
Basophilia
- absolute basophil count of greater than 0.15
9
x 10 /L
- Most common cause is the presence of
malignant myeloproliferative neoplasm such
as chronic myelogenous leukemia
- Nonmalignant causes of basophilia are rare
and include allergic rhinitis, hypersensitivity to
drugs or food, chronic infections,
hypothyroidism, chronic inflammatory
conditions, radiation therapy, and bee stings.
10 of 13
Monocytes
Monocytosis
- absolute monocyte count of greater than 1.0
9 9
x 10 /L in adults and greater than 3.5 x 10 /L
in neonates
- first sign of recovery from acute
overwhelming infection or severe neutropenia
(most commonly after cancer chemotherapy)
- Monocytosis when due to administration of
G-CSF or GM-CSF may be accompanied by
reactive changes in monocyte morphology.
- In cyclic neutropenia, monocytosis occurs
inversely with neutropenia in the 21-day
cycle.
Monocytopenia
9
10 /L
- very rare in conditions that do not also
involve cytopenias of other lineage(s), such
as aplastic anemia or chemotherapy-induced
cytopenias
- Absolute cytopenia has been found in
patients receiving steroid therapy or
hemodialysis, or in sepsis.
- can be caused by viral infections, especially
those due to the Epstein-Barr virus (EBV)
Lymphocytes
Lymphocytosis
- absolute lymphocyte count is higher in
children older than 2 weeks and younger than
8 to 10 years, than adults
- Young children: greater than 10.0 x 109/L
- Adults: greater than 4.5 x 109/L
- newborn infants have lymphocyte counts very
similar to those of adults
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER
QUALITATIVE (MORPHOLOGIC) CHANGES
Neutrophils
Toxic granulation
- dark, blue-black granules in the cytoplasm
- peroxidase (+)
- increased acid mucosubstance within
primary, azurophilic granules
- results to lowered pH in phagolysosomes that
enhances microbial killing
- The intensity of toxic granulation is a general
measure of the degree of inflammation.
- Defining characteristic: not all neutrophils are
equally affected
Dhle bodies
- cytoplasmic inclusions consisting of remnants
of RNA arranged in parallel rows
- typically found in band and segmented
neutrophils and often in cells containing toxic
granulation
- intracytoplasmic, pale blue round or
elongated bodies between 1 and 5 um in
diameter
- usually located in close apposition to cell
membranes
- A delay in preparing the blood after collection
in EDTA tube may affect Dhle body
appearance in that they are more gray than
blue and in some case may not be visible.
Cytoplasmic vacuolation
- reflect phagocytosis, either of self
(autophagocytosis) or of extracellular material
- Autophagocytic vacuoles
Small (2 um)
Distributed throughout the cytoplasm
- Autophagocytosis can be induced by:
Drugs such as sulfonamides and
chloroquine
Acute alcoholism
11 of 13
Storage in EDTA (artefactual) for more
than 2 hours
Exposure to high doses of radiation
- Phagocytic vacuoles
Caused by either bacteria or fungi (often
see in septic patients)
Large (up to 6 um)
Frequently accompanied by toxic
granulation
Ehrlichia and Anaplasma
- Obligate intracellular bacteria
transmitted by tricks to humans and
other vertebrate hosts
- Grow as a cluster (morula) in
neutrophils (A. phagocytophilum and E.
ewingii) and in monocytes (E.
chaffeensis)
Pyknotic nuclei
- Indicate imminent cell death
- Nuclear water has been lost
- Chromatin becomes very dense and dark
- Filaments can still be seen between
segments
Degranulation
- Common finding in activated neutrophils and
eosinophils
- Both primary and secondary granules are
emptied into phagosomes, and secondary
granules are also secreted into the
extracellular space.
- In vitro degranulation in eosinophils often
occurs when cellular membranes are
disrupted during the process of making the
blood film.
Cytplasmic swelling
- Caused by actual osmotic swelling of the
cytoplasm or by increased adhesion to the
glass slide by stimulated neutrophils
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER 12 of 13

- Results to variation in neutrophil size or lymphocytes spill into peripheral circulation,

neutrophil anisocytosis
Monocytes
Immature monocytes may be seen in the
peripheral blood in response to infection or
inflammation (but not as common as
neutrophilic left shift)
Reactive changes
- May be seen in monocytes in infections,
during recovery from bone marrow aplasia,
and after GM-CSF administration
- Nucleus can become thin and band-like in
areas and may appear to be segmenting
- Increased cytoplasmic volume, increased
number of cytoplasmic granules, and
evidence of phagocytic activity (cytoplasmic
vacuolation, intracellular debris, and irregular
cytoplasmic borders)
- Large number of immature monocytes occur
most often in hematologic neoplasms
involving the monocytic series.
which is what is encountered upon smear
review.
Morphologic Changes in Reactive Lymphocytes
- Heterogeneous population of various shapes
and sizes
- There is a variation in the
nuclear/cytoplasmic ratio, nuclear shape, and
the chromatin pattern, which is generally
clumped, but some cells may demonstrate
chromatin patterns that are less mature (less
clumped).
- Nucleoli may be visible.
- Increase in basophilic cytoplasm
- Cytoplasm may be indented by surrounding
RBCs
- Plasmacytoid lymphocyte
A type of reactive lymphocytes that has
some of the morphologic features of
plasmacytes

Lymphocytes
Reactive morphologic changes in lymphocytes
have been described using the terms:
- Variant lymphocytes
- Reactive lymphocytes
- Effector lymphocytes
- Transformed lymphocytes
- Turk cells
- Downey cells
- Immunoblasts
- Atypical lymphocytes (least suitable)
Reactive lymphocytes
- result of complex morphologic and
biochemical events that occur as
lymphocytes are stimulated when interacting
with antigens in peripheral lymphoid organs.
- B and T lymphocyte activation results in the
transformation of small, resting lymphocytes
into proliferating larger cells. These
3GMT 2018
XXIX. NONMALIGNANT LEUKOCYTE DISORDER 13 of 13

Epstein-Barr Virus (EBV)-Related Infections

Most humans are subclinically infected with
EBV, which has been associated with several
benign and malignant diseases but has only
been proven to be the causative agent in a few,
including infectious mononucleosis.

INFECTIOUS MONONUCLEIOSIS (IM)

The symptomatic illness that ensues whenever
adolescents and adults are infected
Incubation period: 3 to 7 weeks
- The virus preferentially infects B lymphocytes
through attachment of viral envelope
glycoprotein 350/200 to CD21 (C3d
complement receptor)
Clinical manifestations:
(Common)
- Sore throat
- Dysphagia
- Fever
- Chills
- Cervical lymphadenopathy
- Fatigue
- Headache
(Less Common)
- Hepatomegaly
- Elevated transaminases
- Splenomegaly
- Hemolytic anemia
- Thrombocytopenia
Hematologic findings
- WBC count is elevated to a range of 10 to 30
9
x 10 /L or more with an absolute
lymphocytosis
- Wide variation in lymphocyte morphology,
with up to 50% or higher exhibiting reactive
features.
- Positive heterophile antibody test
- Positive EBV specific antigen and antibody
tests

3GMT 2018