BdReviewFINAL2006 lq

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Published on November 16, 2007

Author: Abbott

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Interpreting Anemia:  Interpreting Anemia Hematocrit or PCV -- degree of change Determine if regenerative (or not) Absolute reticulocytes (preferred) % reticulocytes Indices: MCV, MCHC RBC morphology (including nRBCs) Reticulocytes for regenerative anemias:  Reticulocytes for regenerative anemias Small animals: Increased absolute reticulocytes > 80,000/µL dog > 60,000/µL cats OR: Corrected reticulocyte % > 1 % Ruminants: any increase in relative or absolute reticulocytes is significant Slide3:  Retic % x Patient PCV = Corrected % Normal PCV Example: 3 % x 15% / 45% = 1% Not adequate… Slide4:  RBC Indices Slide5:  Polychromasia! (except if…) Macrocytosis Howell Jolly bodies, basophilic stippling NRBCs (marrow +/- splenic production) Slide6:  Blood smear from anemic dog. IMHA:  IMHA Markedly regenerative anemia with significant neutrophilic leukocytosis Thrombocytopenia often present (ITP? DIC?) Other rule outs (strongly regen anemia, thrombocytopenia in dog) Babesia (canis or gibsoni) Zn toxicity Bee sting, snake bite Fragmentation anemia (e.g. HSA) Heinz body anemia Follows initial phase of MetHbemia (Caused by oxidant damage to Hb) :  Heinz body anemia Follows initial phase of MetHbemia (Caused by oxidant damage to Hb) Onions, garlic, etc (all species) Copper (sheep) Acetaminophen (cat) Red maple leaves (horse) Zinc (dogs –sometimes) Skunk spray (dogs?) Many Heinz bodies without anemia? cats!:  Many Heinz bodies without anemia? cats! “Normally occurring” Heinz bodies (from increased endogenous oxidants) are not removed in sick cats (e.g. DKA, LSA) Slide12:  Mycoplasma haemofelis, M. Haemocanis M. Haemosuis, etc. Anaplasma marginale Single peripheral inclusion Multiple epicellular cocci and/or rods Slide13:  Babesia canis Large form Babesia gibsoni Small signet ring Pit bulls! Appears similar to Cytauxzoon felis in cats Slide14:  Hepatozoon americanum Anaplasma phagocytophilum (large morulae) Ehrlichia ewingii (small morulae) Viscercal hemangiosarcoma in dogs :  Viscercal hemangiosarcoma in dogs Regenerative anemia (necrotic tumors cause internal blood loss) Schistocytes, spherocytes, acanthocytes* (hemolysis from fragmentation) Thrombocytopenia (DIC) Non-regenerative anemias:  Non-regenerative anemias Low degree of polychromasia, low absolute reticulocyte count Unchanged MCV, MCHC (exceptions: non-regen iron deficiency) Marrow evaluation possibly indicated Non-regenerative anemias I: Decreased erythropoiesis :  Non-regenerative anemias I: Decreased erythropoiesis Anemia of inflammation (“chronic disease”) Anemia of chronic renal disease Endocrine insufficiencies (hypoT, hypoadrenocort) Marrow failure Generalized marrow failure:  Generalized marrow failure Decreased production of all cell lines; pancytopenia on CBC Order of disappearance: neutrophil, PLT, RBCs Examples: estrogen toxicity (dog, ferret) Marrow neoplasia - lymphoma chronic ehrlichiosis (dog) Bracken fern (cattle) Idiosyncratic production of myelotoxic metabolite (dog: TMPS) FeLV Immune-mediated Selective erythropoietic failure Non-regen anemia as only cytopenia :  Selective erythropoietic failure Non-regen anemia as only cytopenia Immune attack to early or late erythroid precursor. Dx: Bone marrow (erythroid hyperplasia with maturation arrest) FeLV-induced red cell aplasia. hrEPO administered excessively to dogs, cats, horses (“pure red cell aplasia”) Non-regenerative anemias II: Ineffective (abnormal) erythropoiesis Erythroid hyperplasia of marrow? :  Non-regenerative anemias II: Ineffective (abnormal) erythropoiesis Erythroid hyperplasia of marrow? Iron deficiency Lead toxicosis Erythropoietic neoplasms Macrocytic, non-regenerative anemias (FeLV in cats, Poodles) Iron deficiency anemia :  Iron deficiency anemia Chronic external blood loss (intestine*), decreased iron intake (nursing neonates - milk) Microcytosis (decreased MCV) Hypochromasia: increased central pallor (decreased MCHC) Reticulocytes: High or low…. Increased NRBCs without non-regenerative anemia or non-anemic (inappropriate) :  Increased NRBCs without non-regenerative anemia or non-anemic (inappropriate) Lead toxicosis (+ basophilic stippling) Heatstroke Marrow neoplasm (LSA most often) Myelofibrosis Splenic disease (HSA) or splenX Glucocorticoid-induced leukogram (“stress” leukogram):  Glucocorticoid-induced leukogram (“stress” leukogram) Mature neutrophilia (up to 2x): MNP to CNP shift Lymphopenia*: decreased re-circulation (+ lysis) Eosinopenia Monocytosis Lymphocytosis (!) in stressed dogs with hypoadrenocorticism (“relaxed” leukogram) Inflammatory leukogram:  Inflammatory leukogram Segmenters: Increased, unchanged or decreased (balance of marrow production and tissue utilization) Bands (left shift): absent or increased Monocytosis Fibrinogen: increased Toxic change in neutrophils Indicate Inflammation! :  Toxic change in neutrophils Indicate Inflammation! Diffuse cytoplasmic basophilia Dohle bodies Cytoplasmic vacuolization (“foamy”) Neutropenia Panic value: < minimum of reference interval :  Neutropenia Panic value: < minimum of reference interval Endotoxemia* Overwhelming inflammation, sepsis* Decreased granulopoiesis*   Parvoviral infection (multiple factors)* Abnormal granulopoiesis  Anti-neutrophil or CSF antibodies Belgian Teruven dogs Specific causes of marked neutrophilia in dogs (>50,000 PMN/µL):  Specific causes of marked neutrophilia in dogs (>50,000 PMN/µL) Pyometra* Hepatozoonosis* (H. americanum, WBC inclusion) Hemolytic anemias* (IHA, erythroparasites) Early estrogen toxicosis Leukocyte adhesion defect (CLAD, BLAD) Paraneoplastic production of CSF Chronic granulocytic leukemia Physiologic leukocytosis Epinephrine (cats, horses, and pigs) Very short duration -- seldom observed!:  Physiologic leukocytosis Epinephrine (cats, horses, and pigs) Very short duration -- seldom observed! Mature neutrophilia (2x) Lymphocytosis (esp age < 1 yr) Abnormal lymphocyte morphology:  Abnormal lymphocyte morphology Reactive lymphocytes Inflammation/antigenic stimulation PL in cattle Neoplastic lymphocytes (leukemia) Mastocytemia:  Mastocytemia Inflammation in dogs (rare) Mast cell leukemia (“mastocytosis”). Buffy coat smears to detect low-grade leukemia when staging MCTs Thrombocytopenia:  Thrombocytopenia Artifact? clumping from sample collection error (EDTA in rare horses) Increased consumption: DIC, (active bleeding) Increased destruction: ITP, EAR Decreased production: marrow failure Sequestration: splenomegaly Coagulation pathways Blood collected 9:1 in citrate:  Coagulation pathways Blood collected 9:1 in citrate Intrinsic: XII, XI, IX, VIII ($12 item sells for 11.98 at Walmart) Extrinsic: VII (activated by Tissue Factor) Common: X, V, II (prothrombin), I (fibrinogen), XIII (fibrin cross-linker) Coagulopathies (hematomas):  Coagulopathies (hematomas) Vit K antagonists (warfarin, diphacinone, etc) or decreased intestinal absorprtion of K (liver disease) --Decreased Factors II, VII, IX, X Increased PT, then PTT Increased PIVKAs Congenial deficiency (“hemophilia”): VIII or IX (dogs), XII (cats) Increased PTT DIC (sepsis, hemolysis, neoplasia, pancreatitis, lepto, etc) :  DIC (sepsis, hemolysis, neoplasia, pancreatitis, lepto, etc) Consumption of factors: prolonged PT and/or PTT (ACT) decreased fibrinogen Consumption of platelets: low PLTs (with increased MPV?) Increased fibrinolysis (plasmin) increased D-dimers and FDPs Consumption of anticoagulants: Decreased antithrombin (AT) Thromboembolism (esp. PTE in dogs):  Thromboembolism (esp. PTE in dogs) Initiated by vascular injury (HWD) or decreased AT (protein-losing glomerulopathy, Hyperadreno) Markedly increased D-dimers* +/- thrombocytopenia von Willebrand’s disease (thrombocytopathy!):  von Willebrand’s disease (thrombocytopathy!) Platelet dysfunction (adhesion of PLT to collagen requires vWF) Platelet count : normal! Prolonged BMBT! (prolonged with decreased function or thrombocytopenia) Rarely, prolonged PTT (vWF also serves as carrier for VIII—w/o vWF, increased clearance of VIII) Dx: Decreased plasma vWF conc. Protein concentration:  Protein concentration Refractometer (g/dL): most effusions Microprotein assay (mg/dL): CSF, urine Effusions:  Effusions Neutrophilic inflammation, non-septic:  Neutrophilic inflammation, non-septic Neutrophils (“non-degenerate” in effusions) Resemble blood neutrophils No microorganisms Effusive FIP in cats Neutrophilic inflammation, septic:  Neutrophilic inflammation, septic Neutrophils (“degenerate” in effusions!) Nucleus stains less basophilic Nuclear lobes swollen, less distinct Phagocytosed bacteria Chylous effusions (pleural):  Chylous effusions (pleural) Latescent appearance of fluid (increased TGs, lipid-laden macrophages) Increased numbers of small lymphocytes Causes: Cranial mediastinal mass Congestive heart failure Idiopathic, trauma Cytology of neoplasms:  Cytology of neoplasms Nuclear features: malignant vs. benign Anisokaryosis** Prominent, variable nucleoli* Cytoplasmic features: determines category (e.g. carcinoma, sarcoma, melanoma, RCT) Carcinomas (SCC, TCC) :  Carcinomas (SCC, TCC) Oval - polygonal shape Centrally located nucleus Exfoliate well Typically occur as clusters Neuroendocrine carcinomas :  Neuroendocrine carcinomas Well-differentiated morphology Minimal anisokaryosis Indistinct cytoplasmic borders! (thyroid, AS apocrine gland) Sarcomas (OSA, HSA, FSA, HPC) :  Sarcomas (OSA, HSA, FSA, HPC) Oval to spindle shape Eccentric location of nucleus Exfoliate poorly (exceptions!) Cells occur singly, few clusters (exceptions!) Matrix granules (pinkish color) OSA:  OSA Osteoblasts: eccentric nucleus, clear Golgi area in cytoplasm, +/- matrix granules (osteoid) Melanomas:  Melanomas Polygonal, spindle, or round cell shape! Variable melanin granulation: heavy to amelanotic Malignant vs. benign? Round cell tumors (skin tumors of the dog) Round and individualized! :  Round cell tumors (skin tumors of the dog) Round and individualized! Histiocytoma Plasmacytoma Mast cell neoplasm Lymphosarcoma Transmissible venereal tumor Histiocytoma:  Histiocytoma Proliferation of cutaneous Langerhan cells Minimal nuclear atypia, low N:C ratio, “fried egg” +/- lymphocytes Age ~ 3 years Plasmacytoma:  Plasmacytoma Cells with eccentric nucleus, basophilic cytoplasm w/ clear Golgi area Marked anisokaryosis, binucleation Mast cell neoplasm:  Mast cell neoplasm Metachromatic granules that obscure nuclear detail. Problem with Diff Quik? Degree of malignancy? +/- eosinophils TVT:  TVT Single prominent nucleoli Condensed (“ropey”) chromatin Clear vacuoles in cytoplasm Eosinophilic inflammation:  Eosinophilic inflammation Hypersensitivity (respiratory: nasal, BAL) Lymphocytic inflammation in CSF:  Lymphocytic inflammation in CSF Small lymphocytes Cause: viral, GME, NE, listeriosis Hemorrhage Equine TTW? Pericardial or abdominal effusion?:  Hemorrhage Equine TTW? Pericardial or abdominal effusion? Blastomyces:  Blastomyces Large, extracellular Broad-based budding Occur in cell clusters Cryptococcus:  Cryptococcus Variably sized (can be small!) Narrow-based budding Clear capsule! Histoplasma:  Histoplasma Small and round with prominent eccentric nucleus Phagocytosed by macrophage or neutrophils Coccidiodes:  Coccidiodes Large (!) spherules (non-budding) Regional occurrence Sporothrix:  Sporothrix Small, oblong to cigar-shaped yeast; phagocytosed Hepatic tests:  Hepatic tests Leakage from hepatocellular damage: ALT, AST*, SDH Induced by cholestasis (+ bone growth, C/S in dogs): ALP Induced by cholestasis: GGT Hepatocellular function: bilirubin, urea, albumin, cholesterol, glucose If needed (!): bile acids (BSP, ICG) Examples of hepatic diseases:  Examples of hepatic diseases Dogs sago or mushroom toxicity (incr. ALT) PSS (microcytosis, normal bilirubin) Leptospirosis (+ renal azotemia) Cats: IHL (ALP > GGT) Cholangiohepatitis Horses: Pyrollizidine toxicosis Foals with Clostridium piliformis (Tyzzers) Chemistry panel from dog:  Chemistry panel from dog ALP 3,000 IU/L H Cholesterol 450 mg/dL H All other serum chemistries are unremarkable Chemistry panel from dog:  Chemistry panel from dog Cholesterol 450 mg/dL H All other serum chemistries are unremarkable Chemistry panel from dog:  Chemistry panel from dog Calcium 6.8 mg/dL L Albumin 1.8 gm/dL L Globulins 2.0 gm/dL L Cholesterol 65 mg/dL L All other serum chemistries are unremarkable Special test? Renal tests:  Renal tests Glomerular filtration rate (decreased at ~ ¾ loss) BUN, creatinine, phosphorus (Increased BUN with normal creatinine?) Tubular function (decreased at ~ ⅔ loss) Concentrating ability: urine specific gravity Tubular function: glucosuria if less absorption Filtration barrier of glomeruli (+/- azotemia) Increased urinary protein (P:C, microalbuminuria) (Amyloidois and G.N. can induce “nephrotic syndrome”) Appropriate renal concentrating ability indicated by urine SG (pre-renal vs. renal azotemia) :  Appropriate renal concentrating ability indicated by urine SG (pre-renal vs. renal azotemia) Cats > 1.035 Dogs > 1.030 Horses, > 1.025 cattle Diseases with inappropriately dilute urine (when USG lies) :  Diseases with inappropriately dilute urine (when USG lies) Diabetes mellitus (osmotic) Hyperadrenocorticism (ADH) Hypoadrenocorticism (sodium) Hypercalcemia (ADH) Liver disease (urea) Pyometra (endotoxin, ADH) Acid-base:  Acid-base Metabolic control: HCO3 (aka TCO2) Increased: alkalosis, Decreased: acidosis Respiratory control: pCO2 Increased: acidosis, Decreased: alkalosis Increased anion gap: accumulation of acids (detected as unmeasured anions) that titrate HCO3 (metabolic acidosis) [Na + K] – [Cl + HCO3] Renal acids (any type of azotemia) Lactic acidosis from anaerobic glycolysis Ketones Ethylene glycol (glycolates, renal acids) Hypoadrenocort, urinary obstruction, uroabdomen, oliguric (“acute”) renal failure, diarrhea (esp. whipworm), effusion drainage:  Hypoadrenocort, urinary obstruction, uroabdomen, oliguric (“acute”) renal failure, diarrhea (esp. whipworm), effusion drainage Cr, BUN, Phos Increased USG Variable (pre, renal or post-?) Na Decreased Cl Decreased K Increased* (Na:K ratio < 27) Bicarb Decreased AG Increased pCO2 Compensatory decrease Gastric outflow obstruction, gastric vomiting, furosemide, gastric/abomasal sequestration, bovine azotemia :  Gastric outflow obstruction, gastric vomiting, furosemide, gastric/abomasal sequestration, bovine azotemia Na Unchanged* Cl Decreased* K Decreased (renal, gastric loss) Bicarb Increased* Cr, BUN, Phos Increased (pre-renal) AG Increased (mixed!) pCO2 Compensatory increase? Paradoxic aciduria may occur with dehydration, met. alkalosis, and hypochloridemia. Diarrhea :  Diarrhea Na, Cl Decreased K Decreased (later, may increase) Bicarb Decreased AG Initially unchanged! (Bicarb lost, no accumulated acids) pCO2 Compensatory decrease Later, AG increases when fluid loss causes pre-renal azotemia, LAosis. Hypercalcemia :  Hypercalcemia Hyperparathyroidism* Osteolytic lesion (?) Granulomatous inflammation (Blasto*) Spurious (lipemic interference?) Neoplasia (increased PTHrp)* Young animals* Addisons disease* Renal failure (esp. equine)* D (Vitamin D toxicosis)* Hypocalcemia:  Hypocalcemia Hypoalbuminemia (“correct” in dogs?) Lactation tetany Ethylene glycol Acute pancreatitis Chronic renal disease Hypoparathyroidism Decreased Vit D absorption (PLE) Cantharidin Hypomagnesiumemia (grass tetany, PLE) Sepsis Hypoglycemia:  Hypoglycemia Decreased hepatic synthesis Neonates Hepatic disease Ketosis Decreased insulin antagonists: Hypoadrenocorticism Paraneoplastic Insulin: Insulinoma ILGF: leiomyoma/sarcoma, hepatic CA Sepsis (increased catabolism) Delayed separation of serum/plasma from blood tube (esp if leukocytosis present)

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