B-Cells and T-Cells

These specialized cells are a critical part of the bodies humoral immune system. They recognize foreign antigens or invaders and mount a quick response. B-cells act quickly by developing antibodies to the antigen epitopes. T-cells react based on what serological class they are in. If it is a CD8 T-cell, its cytotoxic and can quickly fight and phagocytize the antigen, if it is a CD4 T-cell, it works in conjunction with B-cells and other T-cell subclasses to defend the host. This article will dive into B-cells, and every subclass of T-cells and how they work together to form the humoral branch of the immune system.

B-Cells

B-cells also known as B lymphocytes are a type of lymphocyte that functions as part of the humoral component of the adaptive immune system. It’s role is to secrete antibodies, but it also functions as an antigen-presenting cell (APC) that secretes cytokines. It possesses a B-cell receptor (BCR) on its surface that allows it to bind to a specific target antigen and initiate an immune response. B-cells develop from hematopoietic stem cells (HSCs) that originate within the bone marrow. They then develop into multipotent progenitor cells (MPP), which further differentiates into the common lymphoid progenitor (CLP). Development further progresses through several stages through various gene expression patterns and arrangements. Before maturation occurs, positive selection takes place to make sure that the pre-BCR and BCR can recognize and bind to specific ligands through antigen-independent signaling. If the cells are unable to bind, these B-cells cease to develop. Negative selection occurs through binding of self-antigen with the BCR. If the BCR is able to bind self-antigen it undergoes four fates; clonal deletion, receptor editing, anergy, or ignorance. Clonal deletion is the destruction of the B-cell through programmed cell death, in other words known as apoptosis. This is only for those B-cells that have expressed receptors for self-antigens. Receptor editing is exactly what the name suggests; editing of the BCR during the maturation process in an attempt to change the specificity the receptor to not recognize self-antigens. Anergy is used to describe lack of reaction by the bodies immune system. Its a way of saying that the B-cells that express BCRs for self-antigen will simply not be used. The last fate; ignorance means that the B-cell ignores the signal and continues through natural development. When negative selection is complete, the B-cells are now in a state of central tolerance. These mature B-cells do not bind with self antigens. From the bone marrow, B-cells migrate to the spleen as transitional B-cells. Within the spleen they become Follicular B-cells or Marginal zone B-cells depending on the signal received through the BCR. Once completely differentiated, they are now called naive B-cells.

B cell

B-Cell Activation

Activation usually occurs within the secondary lymphoid organs, such as the spleen and the lymph nodes. This is where naive B-cells are positioned once mature. When these naive immunocompetent B-cells encounter an antigen through its BCR, the antigen is internalized by receptor-mediated endocytosis, digested, and positioned on MHC II molecules on the B-cell surface. This allows the B-cell to act as an antigen-presenting cell to T-cells. T-cell dependent activation requires a T-cell helper, most commonly a follicular T-helper cell, to bind to the antigen-complexed MHC II molecule on the B-cell surface through its T-cell receptor (TCR) which drives T-cell activation. These T-cells express the surface protein CD40L and secrete cytokines IL-4, and IL-21 which bind to CD40 on the B-cell surface and act as co-stimulatory factors for B-cell activation. The co-stimulatory factors promote proliferation, immunoglobulin class switching, and somatic hypermutation. Activated T-cells then provide a secondary wave of activation that cause the B-cells to proliferate and form germinal centers. During the production of these germinal centers, activated B-cells may differentiate into plasma blasts, which can produce weak IgM antibodies. Within the germinal centers, B-cells differentiate into high affinity memory B-cells or long-lived plasma cells. The primary function of plasma cells is the secretion of clone-specific antibodies. There are very few antigens that can directly provide T-cell independent B-cell activation. Some components of bacterial cell walls (lipopolysaccharide), and bacterial flagellin are some to name a few. One other mechanism through which B-cell activation is enhanced is through the activity of CD21, CD19, and CD81; all three are surface proteins that form a complex. When the BCR binds to an antigen that is tagged with the complement protein C3, CD21 binds to C3, and downstream signaling lowers the activation threshold of the cell.

Memory B-cell Activation

Activation begins through detection and binding of the target antigen. When the antigen binds, it is taken up by the B-cell through receptor-mediated endocytosis, degraded, and presented onto the MHC II molecule within the B-cell surface. The memory B-cell then acts as an antigen-presenting cell that presents the antigen:MHC II complex to T-cells. Most commonly memory follicular T-helper cells that bind through their TCR. The memory B-cell is then activated and differentiates into either plasmablasts and plasma cells or generate germinal centers.

T-Cells

A T-cell is another lymphocyte, which is a subset of white blood cells. They are called T-cells because they mature in the thymus from thymocytes. There are several subsets of T-cells, each with a specific role in the immune system. These T-cells, just like B-cells originate from hematopoietic stem cells in the bone marrow. These lymphoid progenitor cells populate the thymus and expand by cell division to immature thymocytes. The earliest thymocytes do not express either CD4+ or CD8+ and are classified as double negative cells. Through progression they become double positive and then eventually differentiate into single positive cells, either becoming CD8+, or CD4+. Its interesting to note that there is a small population of double positive T-cells within the peripheral circulation, although their function is unknown. About 98% of thymocytes undergo apoptosis during the development process by failing either positive selection or negative selection. The 2% that survive leave the thymus and become mature immunocompetent T-cells. Lets review positive and negative selection again. Positive selection selects for T-cells that are capable of interacting with MHC molecules. During positive selection signals by double positive precursors express either MHC class I or II receptors. A thymocytes fate is determined during positive selection. Double positive CD4+/CD8+ cells that interact with MHC class II molecules eventually become CD4+ cells, and on the contrary thymocytes that interact well with MHC class I molecules mature into CD8+ cells. Negative selection removes thymocytes that are capable of strongly binding with self MHC peptides.

Difference-Between-T-cells-and-B-cells-

T-Helper Cells

T-helper cells do just what their name suggests, they help other cells in immunological processes. This is evident in the activation of B-cells talked about previously. These cells are also most well known as CD4+ T-cells because the highly express CD4 glycoprotein on their surfaces. These T-cells become activated when they are presented with peptide antigens or epitopes by MHC class II molecules, usually present on antigen-presenting cells. Once activated, these cells proliferate rapidly and secrete multiple cytokines. T-helper cells differentiate into several subtypes; TH1, TH2, TH3, TH17, TH9, and THF, each secreting different cytokines to facilitate different pathways of the immune response. This is an article for another time.

TCellSubsets3-01

Cytotoxic T-Cells

These killer T-cells destroy virus-infected cells and tumor cells. These cells are known as CD8+ T-cells since they express the CD8 glycoprotein on their surface. These cells recognize targets by binding to antigen epitopes that are associated with MHC class I molecules. Cytotoxic T-cells are highly regulated by Regulatory T-cells through IL-10, adenosine, and other molecules. They can be inactivated to an anergic state, which prevents autoimmune diseases.

T-cell CD8

Memory T-Cells

These memory T-cells are long-lived and when presented with an antigen that is recognized they can quickly expand and differentiate into large numbers of effector T-cells. These memory T-cells can either be CD4+ or CD8+ T-cells. There are four subtypes of memory T-cells that will be discussed below.

Central memory T-cells express CD45RO, C-C chemokine receptor type 7 (CCR7) and L-selectin which are all surface protein markers. They have high expression of CD44, and is commonly found within the lymph nodes.

Effector memory T-cells express CD45RO, but lack expression of CCR7 and L-selectin. These T-cells also have high expression of CD44, but are not found in the lymph nodes. These T-cells are found in the peripheral circulation and tissues.

Tissue resident memory T-cells occupy tissues without recirculating. The one specific surface marker that is associated with these cells is integral aeB7.

Virtual memory T-cells differ from all other memory subsets in that they do not originate from a clonal expansion event. These cells reside at low frequencies.

Natural Killer T-cells (NK)

First off, it should be mentioned that these cells should not be confused with natural killer cells of the innate immune system. Unlike conventional T-cells that recognize antigen epitopes presented on MHC I/II molecules, NKT cells recognize glycolipid antigens presented by a molecule called CD1d. When these cells are activated, these cells perform functions from both T-helper cells and cytotoxic T-cells. These cells specialize in recognizing tumor cells and cells infected with herpes viruses.

 

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Non-Malignant Leukocyte Disorders

Non-Malignant simply means that it is localized to the leukocytes. Leukocytes are another name for the white blood cells, more specifically in the case of these disorders, the granulocytes. These disorders are fairly uncommon and are inherited. The following are ones that are found to distinct morphological features and affect the granulocyte functionality.

Alder Reilly Anomaly

Alder Reilly Anomaly is a recessive trait defect that causes incomplete degranulation of mucopolysaccharides. Large, darkly staining metachromatic cytoplasmic granules which can be seen and are partially digested mucopolysaccharides. These granules are characteristically referred to as Alder Reilly bodies. These can sometimes resemble toxic granulation, but it is important to note that in toxic granulation neutropenia, dohle bodies, and a left shift is seen. In Alder Reilly Anomaly none of those are present. Its also important to mention that the functionality of the granulocytes is not impaired.

Alder Reilly

Pelger Huet Anomaly

Pelger Huet Anomaly is an autosomal dominant syndrome characterized by decreased nuclear segmentation. This is caused by a mutation in the Lamin B receptor gene. Lamin B is an inner nuclear membrane protein that plays a role in normal leukocyte nuclear shape change during maturation. Morphological changes include hyposegmented neutrophils or neutrophil lobes connected by a thin nuclear filament. Pseudo or acquired PHA can be observed in the granulocytes in individuals with MDS, AML, or chronic myeloproliferative neoplasms.

Pelger Huet

Chediak Higashi Syndrome

Chediak Higashi Syndrome is characterized by an abnormal fusion of granules. These present as large and are dysfunctional. This is caused by a mutation in the LYST, or CHS1 gene that encodes for proteins involved in vesicle fusion or fission. The mutated protein causes loss of lysosomal movement and loss of phagocytosis. Thus leaving the individual susceptible to an increased number of infections without the innate immune system to fight them off. One of the characteristic findings is neutropenia.

CHA

May-Hegglin Anomaly

May-Hegglin Anomaly is a rare autosomal dominant platelet disorder that is characterized by variable thrombocytopenia, giant platelets, and dohle bodie like inclusions in the granulocytes. MHA is caused by a mutation in the MYH9 gene that causes a dysfunctional and disarray production of myosin heavy chains type IIa which affects the megakaryocytic maturation process as well as platelet fragmentation. Though most cases are clinically asymptomatic, the individual may present with mild bleeding tendencies.

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Chronic Granulomatous Disease

In CGD, mutations in proteins that make up the NADPH oxidase complex. The mutations lead to failure of the phagocytes to generate the oxygen-dependent respiratory burst following phagocytosis. Normal phagocytosis of a microorganism leads to phosphorylation of cytosolic P47 and P67. Antibacterial neutrophil elastase and cathepsin G from the primary granules and cytochrome complex gp91 and gp22 from the secondary granules migrate to the phagolysosome. NADPH oxidase is formed when P47 and P67 combine with P40, RAC2, and the cytochrome complex. Majority of cases of CGD is due to mutations in P47 or gp91.

Leukocyte Adhesion Disorders

Normal recruitment of leukocytes to a site of inflammation involves capture of leukocytes from peripheral blood, followed by a process known as rolling along a vessel wall. Rolling involves binding of integrins to endothelial cell receptors which is high-affinity which ultimately leads to diapedesis of leukocytes into tissues from peripheral blood. With Leukocyte Adhesion disorders there are mutations that result in the inability of neutrophils and monocytes to adhere to endothelial cells, and the consequence is potentially fatal bacterial infections.

Leukocyte Adhesion Disorder I is caused by a mutation in the genes responsible for B2 integrin subunits. This leads to a decreased amount of the truncated form of the B2 integrin which is essential for endothelial cell adhesion. Patients typically present with neutrophilia, lymphadenopathy, splenomegaly, and characteristic skin lesions.

Leukocyte Adhesion Disorder II is caused by a mutation in the SLC35C1 gene. This gene encodes for a fucose transporter that moves fucose from the endoplasmic reticulum to the Golgi region. Fucose is needed for the synthesis of selectin ligands. The defective fucose transporter leads to the inability to produce functional selectins and causes defective leukocyte recruitment and reoccurring infections. LADII is much more rare than LADI. Clinical presentation is growth retardation, coarse facial features, and other physical deformities.

Leukocyte Adhesion Disorder III is even more rare than LADII and is caused by a mutation in the Kindlin-3 gene. The mutations impair leukocyte rolling and activation of B integrin. With LADIII there is also decreased platelet integrin GPIIbIIIa resulting in bleeding similar to that of Glanzmann Thrombasthenia.

-Caleb

Case Study Mini-Series; Diagnostic Process and Treatment

Diagnostic workup of a suspected patient with APL should include a case history and physical examination with focus on bleeding tendencies, recurrent infections and anemic symptoms such as fatigue or pallor. A complete blood count with a differential should be performed. During a peripheral blood smear the technologist should be looking for abnormal promyelocytes with abundant azurophilic granulation and multiple auer rods. A bone marrow aspirate with cytology, cytochemistry, immunophenotyping, FISH, RT-PCR, and cytogenetics should be included. Diagnostic coagulation tests such as PT, aPTT, fibrinogen, and a D-dimer should be performed. During the immunophenotyping the characteristic phenotype of APL is CD33, CD13, CD45, CD64, and CD117 positive. Also APL is HLA-Dr negative which differentiates it from other AMLs which are HLA-Dr positive.

Early initiation of induction therapy ATRA before confirmation of diagnosis has changed the management of APL. APL is curable due to the initiation of ATRA. APL is considered a severe hematologic emergency due to its rapidly progressing bleeding diathesis and risk of intracerebral hemorrhage. Making a presumptive diagnosis based on the peripheral blood smear and bone marrow aspirate along with the patient history is important because the earlier that the patient begins therapy the better the outcome. ATRA and blood product support should be started as early as possible. APL blasts are highly sensitive to anthracyclines. Anthracycline chemotherapy with combination ATRA boasts remission rates of more than 90%. ATRA otherwise known as all-trans retinoic acid is a derivative of retinoic acid which reverses the differentiation block of APL blasts. Arsenic therapy with arsenic trioxide is approved in Europe and the United States for relapsed and refractory APL.

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Aggressive supportive therapy involves FFP, cryoprecipitate and platelets to maintain platelet levels greater than 30,000-50,000/uL and fibrinogen levels above 150 mg/dL. This regimen typically lasts during the first week of induction therapy while the coagulation disorder resolves.

There are significant adverse effects with therapy for APL. A common complication during induction therapy with ATRA or ATO (arsenic) is the development of hyperleukocytosis. APL differentiation syndrome is a life-threatening complication that develops a fever, edema/weight gain, respiratory distress, lung infiltrates, and pleural or pericardial effusions. Differentiation syndrome typically occurs within the first two weeks of the onset of therapy. Intravenous Dexamethasone is recommended immediately in the suspicion of APL differentiation syndrome. In mild cases of differentiation syndrome, ATRA or ATO therapy can just be interrupted and continued after symptoms regressed and when leukocyte counts decrease. Arsenic trioxide toxicity causes electrolyte shifts, particularly involving potassium and magnesium which to no surprise can alter ECG readings causing most commonly a QT interval prolongation. ATO therapy must be discontinued in severe prolongations due to the increased risk of cardiac arrhythmias. Documented chemotherapy adverse effects include the typical nausea and vomiting, increased infections, anemia, thrombocytopenia, increased bleeding tendencies which is exacerbated due to the coagulopathy associated with APL, and cardiac effects. With long-term chemotherapy there is an increased risk of drug-induced secondary malignancies.

Choice of treatment and timing of treatment is extremely important. As mentioned earlier it is very important to start induction therapy upon the first suspicion of APL, even before molecular confirmation occurs.

-Caleb

Case Study Mini-Series; Diagnosis

The patient was diagnosed with subclinical DIC because complications from Acute Promyelocytic Leukemia (APL)

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The characteristic chromosomal translocation of Acute Promyelocytic Leukemia is the break and fusion of the PML gene located on chromosome 15 and the RARA gene located on chromosome 17. This results in a t(15;17) which is detectable in more than 90% of cases. The PML gene has a physiological role in apoptotic pathways and in genomic stability. The t(15;17) breakpoint in PML can occur in three different sites; bcr1 within intron 6, bcr2 within exon 6, and bcr3 within intron 3 . The RARA receptor is active in different variations within each tissue and is important for granulopoiesis. The PML-RARA fusion transcripts impair signaling which is mediated by RARA and interact with proteins that leads to the delocalization of normal PML from its nuclear structures known as NBs. It is in this way that the PML-RARA oncoprotein negatively acts on the normal physiology of the native PML protein. APL is a subtype of AML that has distinctive morphological, biological and clinical characteristics. It is classified as AML-M3 in the French-American-British (FAB) classification system. The cure rate for APL is ~80-90% for patients who survive induction therapy with ATRA. Before ATRA, the 10-day survival rate with treatment was 9.4%. A high blast count was significantly associated with hemorrhagic events and fatality within the first 10 days. A high blast count and thrombocytopenia was associated with death within 24 hours upon admission and treatment. APL predominantly affects a wide spectrum of individuals between the ages 20 and 59 with no gender discrimination. 10-15% of all AML diagnosed in adults is APL, although it can be seen in distinct populations in a higher percentage. 28.2% of all AML diagnosed in Brazil is APL, and 20% of all AML in Venezuela is APL.

APL presents as a bleeding diathesis and coagulopathy. The more common hypergranular variant of APL presents with leukopenia while the less common microgranular variant tends to be more aggressive and presents with leukocytosis. The malignant promyelocytes have specific properties that interact with the host cells. Maligant APL cells express tumor associated procoagulants; Tissue factor (TF) and cancer procoagulant (CP). Tissue factor is an activator of coagulation and the relative expression is elevated significantly in patients with APL.

APL is characterized as a hyperfibrinolysis state. Fibrinolysis is normally activated by thrombin as the fibrin clot develops and coagulation comes to an end. Malignant promyelocytes highly express annexin-II. Annexin-II is a protein receptor that has a strong affinity to plasminogen and tissue-type plasminogen activator (tPA) which results in strong yield of plasmin which initiates fibrinolysis. Annexin-II is highly expressed in the cerebral microvascular endothelial cells explaining the high prevalence of intracerebral hemorrhage in patients with APL. Cytokine release of IL-1B and TNFa by malignant promyelocytes upregulate apoptosis and upregulate the expression of tissue factor on endothelial cells. It is also common for the cytokines to cause loss of the anti-coagulant cofactor thrombomodulin. These various factors lead to APL-associated coagulopathy commonly seen.

Patients with APL present low fibrinogen levels, low platelet count, and an elevated PT-INR, aPTT, and D-dimer. In DIC secondary to APL, fibrinogen survival is markedly decreased due to rapid consumption and the liver can’t produce the product fast enough. Sometimes more specialized tests are needed to diagnose the coagulopathy in APL. Levels of thrombin-antithrombin complex (TAT), prothrombin fragment 1 and 2, and fibrinopeptide A are all increased and all indicate coagulation activation. Decreased levels of plasminogen, and a-2-antiplasmin further support the hyperfibrinolysis state. Sometimes it is helpful to further evaluate the coagulation process and its components. Protein C and antithrombin III are synthesized in the liver and are relatively normal in APL associated coagulopathy unless the maligancy is accompanied by hepatic dysfunction.

The next installment of the mini-series will focus on the key points of what lead to the diagnosis, what I look for as a medical laboratory professional in aiding the doctor in the diagnosis, and how to treat appropriately.

 

-Caleb

 

37-year-old South American Male Case Study Mini-Series

The purpose of this mini-series is to get in the mind of a treating physician when a patient such as this presents to the clinic or the ED in this case. The first part of this series is the introduction of the case with case history and initial lab testing. Please don’t hesitate to leave comments on what you think the diagnosis is and what other confirmatory tests need to be done if any as well as what treatment should consist of. This is mean’t to stimulate a discussion and there are no wrong answers. I am in no way a physician or at that level or have that education. I am a student with a passion for molecular diagnostics and creating these cases is a good way for me to practice real life scenarios through careful and diligent research as well as help others who think the same way. This case is no way real and all lab values are made up to the best of my knowledge. If anything is incorrect please do not hesitate to email me or  leave a comment.

CASE:

A 37-year-old South American male presented to his annual physical with his primary care physician with general fatigue, decreased appetite and weight loss over the past three weeks. The patient mentioned to his physician that he has had multiple nosebleeds throughout the last few weeks, an occurrence of multiple a week. The patients past medical history is unremarkable. No family history of bleeding tendencies. He is not taking any prescription medication and denies use of recreational drugs and only social use of alcohol. His physician ordered a CBC and a prothrombin time/activated partial thromboplastin time (PT/aPTT). Results are in table 1.

Two days later the patient presented to the emergency room with fever and heavy fatigue, he explained to the attending that it has been hard to do anything the last few days, and has been bed-ridden. Physical exam revealed bilateral bruising on the upper arms and forearms with purpura and petechiae. The attending physician ordered a full coagulation panel, platelet function tests (Ristocetin cofactor assay), bleeding time test for vWD, and full CBC with peripheral blood smear analysis. Results are summarized in table 2.

Later that evening the patient developed a high fever, and back/flank pain and was moved to the ICU. Blood cultures, CRP and a procalcitonin was ordered, results are in table 3.

Positive cultures for Staphylococcus aureus were found after 48-96 hours and the patient was started on a course of vancomycin and monitored closely.

Patient results indicated he was pancytopenic with a hemoglobin of 9.7 g/dL (Ref. 13.5-18.0 g/dL) and RBC count of 3.7×10^3/uL (Ref. 4.20-6.00×10^6 uL) with severe thrombocytopenia at 37×10^3/uL (Ref. 150-450×10^3/uL).

Initial coagulation results revealed significantly elevated PT and aPTT. The bleeding time test along with the results from the RCO indicate platelet dysfunction or acquired inhibition of platelets by accelerated destruction. Platelet aggregation studies were normal. RCO studies indicate factor VIII inhibition or consumption.

The peripheral blood smear confirmed leukopenia and thrombocytopenia and revealed abnormal promyelocytes with abundant azurophilic granulation and multiple auer rods in bundles. RBC morphology showed schistocytes and fragmented cells.

The attending followed up by ordering a complete fibrinogen, D-dimer and a plasminogen panel. Results are in table 4.

The significantly elevated D-dimer, elevation in t-PA and u-PA in combination with the significant decrease in fibrinogen, and plasminogen levels indicates primary hyperfibrinolysis.

The attending sent a blood sample to the Blood Bank laboratory and asked for units of packed red cells, platelets, and fresh frozen plasma (FFP) to be transfused. With the additional blood components, the patient was able to regain control over the thrombocytopenia, hemoglobin, fibrinogen and coagulation factor levels.

A bone marrow aspirate was ordered including cytology, cytochemistry, immunophenotyping, FISH (Fluorescence in situ hybridization), cytogenetics (chromosomal analysis and FISH) and RT-PCR for PML/RARA quantification of transcripts. The attending started the patient on all-trans retinoic acid (ATRA) as induction therapy.

FISH revealed the PML-RARA fusion gene present which was later quantified and confirmed by RT-PCR. PCR sequencing revealed a bcr-3 PML-breakpoint. Chromosomal analysis of the bone marrow identified a t(15;17) classic translocation. Cytochemistry revealed intensely positive reacting cells to myeloperoxidase and Sudan black B. Immunophenotyping results are in table 5.

Table 1:

RBC: 4.10×10^6/uL             4.20-6.00×10^6/uL          

HGB: 12.9 g/dL                    13.5-18.0 g/dL        

HCT: 38.7%                          40-54%

MCV: 88 fL                            80-100 fL

MCH: 33.2 pg                        26-34 pg

MCHC: 32.3 g/dL                  32-36 g/dL

RDW: 13.5%                         11.5-14.5%

RETIC: 0.8%                          0.5-2.5%

NRBC: 0/100 WBC               0

WBC: 6.3×10^3/uL              3.6-10.6×10^3/uL

NEUT: 3.6×10^3/uL             1.7-7.5×10^3/uL

LYMPH: 1.9×10^3/uL          1.0-3.2×10^3/uL

MONO: 0.7×10^3/uL           0.1-1.3×10^3/uL

EO: 0.1×10^3/uL                  0.0-0.3×10^3/uL

BASO: 0                                 0.0-0.2×10^3/uL

PLT: 111×10^3/uL              150-450×10^3/uL

MPV: 7.3 fL                           7.0-12.0 fL

 

PT: 21 seconds                    11-14 seconds

aPTT: 37 seconds               25-35 seconds

Table 2:

RBC: 3.7×10^3/uL              4.20-6.00×10^3/uL

HGB: 9.7 g/dL                     13.5-18.0 g/dL                    

HCT: 28.9%                          40-54%

MCV: 71 fL                            80-100 fL

MCH: 31.8 pg                       26-34 pg

MCHC: 33.1 g/dL                 32-36 g/dL

RDW: 15.1%                        11.5-14.5%

RETIC: 2.3%                         0.5-2.5%

NRBC: 0/100 WBC               0

WBC: 2.5×10^3/uL             3.6-10.6×10^3/uL

NEUT: 1.3×10^3/uL           1.7-7.5×10^3/uL    

LYMPH: 0.7×10^3/uL         1.0-3.2×10^3/uL

MONO: 0.3×10^3/uL          0.1-1.3×10^3/uL

EO: 0.1×10^3/uL                 0.0-0.2×10^3/uL

BASO: 0.1×10^3/uL            0.0-0.3×10^3/uL

PLT: 37×10^3/uL               150-450×10^3/uL

MPV: 19.3 fL                       7.0-12.0 fL

 

Myeloblasts: 7%                  0%

Promyelocytes: 54%         0%

Myelocytes: 3%                    0%

Metamyelocytes: 5%           0%

Bands: 0%                             0%

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PT: 33 seconds                   11-14 seconds

aPTT: 63 seconds              25-35 seconds

BT: 13 minutes                   1-9 minutes

RCO: 30%                              50-150%

Platelet aggregation studies: Normal

Table 3:

Blood Cultures: POS Staph aureus          NEG

Procalcitonin: 0.25 ng/mL                        <0.15 ng/mL

CRP: 23 mg/L                                                0-10 mg/L

Table 4:

Fibrinogen: 67 mg/dL

Plasminogen: Reduced

a2-Antiplasmin: Reduced

t-PA: Elevated

u-PA: Elevated

D-Dimer: >19,000 ng/mL    

Table 5:

CD2                NEG

CD4                NEG

CD13              POS

CD14              NEG

CD16              NEG

CD19              NEG

CD33              POS

CD34              NEG

CD45              POS

CD56              NEG

CD64              POS

CD117            POS

HLA-DR         NEG

 

-Caleb