Ebook Essentials of clinical pathology Part 1

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Ebook Essentials of clinical pathology Part 1

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(BQ) Part 1 book Essentials of clinical pathology presentation of content: Examination of urine, renal function tests, diabetes mellitus, liver function tests, examination of cerebrospinal fluid, examination of sputum, examination of feces, gastric analysis, thyroid function tests,... and other contents.

Essentials of ir s ns ia rs p e vi p ta h ir9 -U ni te dV R G Clinical Pathology tahir99 - UnitedVRG vip.persianss.ir R G dV p e rs ia ns s ir te ni -U ir9 ta h vi p tahir99 - UnitedVRG vip.persianss.ir Essentials of te dV R G Clinical Pathology s ia rs p e vi p ta h ir9 ns -U ni Associate Professor Department of Pathology Government Medical College Nagpur, Maharashtra, India ir Shirish M Kawthalkar ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD Nagpur • St Louis (USA) • Panama City (Panama) • London (UK) • New Delhi • Ahmedabad Bengaluru • Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai tahir99 - UnitedVRG vip.persianss.ir R G Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd dV Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314 ns p e rs ia ir9 Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: ahmedabad@jaypeebrothers.com Bengaluru, Phone: Rel: +91-80-32714073, e-mail: bangalore@jaypeebrothers.com Chennai, Phone: Rel: +91-44-32972089, e-mail: chennai@jaypeebrothers.com Hyderabad, Phone: Rel:+91-40-32940929, e-mail: hyderabad@jaypeebrothers.com Kochi, Phone: +91-484-2395740, e-mail: kochi@jaypeebrothers.com Kolkata, Phone: +91-33-22276415, e-mail: kolkata@jaypeebrothers.com Lucknow, Phone: +91-522-3040554, e-mail: lucknow@jaypeebrothers.com Mumbai, Phone: Rel: +91-22-32926896, e-mail: mumbai@jaypeebrothers.com Nagpur, Phone: Rel: +91-712-3245220, e-mail: nagpur@jaypeebrothers.com ta h • • • • • • • • • ir Offices in India s -U ni te Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com Essentials of Clinical Pathology © 2010, Shirish M Kawthalkar vi p Overseas Offices • North America Office, USA, Ph: 001-636-6279734, e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com • Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: cservice@jphmedical.com, Website: www.jphmedical.com • Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: info@jpmedpub.com All rights reserved No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher This book has been published in good faith that the material provided by author is original Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s) In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only First Edition: 2010 ISBN 978-93-80704-19-7 Typeset at JPBMP typesetting unit Printed at tahir99 - UnitedVRG vip.persianss.ir Preface ir s ns ia rs p e vi p ta h ir9 -U ni te dV R G The major aims of this book are discussion of (i) use of laboratory tests in the investigation and management of common diseases, and (ii) basic biochemical and pathological principles underlying the application of laboratory tests The book has been written keeping in mind mainly the curricula of undergraduate students of pathology It should also prove to be appropriate for postgraduate residents and students of medical laboratory technology The laboratory tests that are demonstrated to and performed by medical students in pathology practical class and during university examination are given in more detail To keep pace with new knowledge and advances, principles of currently performed techniques in clinical laboratory practice have also been outlined Most of the chapters are followed by reference ranges and critical values for ready access Critical values or action values are those laboratory results that require immediate attention of the treating clinician While interpreting results of laboratory tests, it is necessary to follow two fundamental rules of laboratory medicine: (i) diagnosis should never be made from a single abnormal test result (since it is affected by a number of preanalytical and analytical factors), and (ii) try to arrive at a single diagnosis (rather than multiple diagnoses) from all the abnormal test results obtained Clinical pathology is the second major subdivision of the discipline of pathology after anatomic pathology It is concerned with laboratory investigations for screening, diagnosis, and overall management of diseases by analysis of blood, urine, body fluids, and other specimens The specialties included under the discipline of clinical pathology are clinical chemistry, hematology, blood banking, medical microbiology, cytogenetics, and molecular genetics However, scope of this book does not allow microbiology and genetics to be included in this book I must appreciate and recognize the unstinting support of my parents, my beloved wife Dr Anjali, and my two children, Ameya and Ashish during preparation of this book I am thankful to Dr HT Kanade, Dean, Government Medical College, Akola, Dr Smt Deepti Dongaonkar, Dean, Government Medical College, Nagpur, Dr BB Sonawane, Professor and Head, Department of Pathology, Government Medical College, Akola, and Dr WK Raut, Professor and Head, Department of Pathology, Government Medical College, Nagpur, for encouraging me in undertaking this project for the benefit of medical students I express my thanks to Mr JP Vij and his outstanding team of M/s Jaypee Brothers Medical Publishers for undertaking to publish this book, being patient with me during the preparation of the manuscript, and bringing it out in an easy-to-read and reader-friendly format Although I have made every effort to avoid any mistakes and errors, some may persist and feedback in this regard will be highly appreciated Shirish M Kawthalkar tahir99 - UnitedVRG vip.persianss.ir R G dV p e rs ia ns s ir te ni -U ir9 ta h vi p tahir99 - UnitedVRG vip.persianss.ir Contents Section Chemical Pathology and Related Studies Examination of Urine Renal Function Tests 30 Diabetes Mellitus 39 Liver Function Tests 52 Disorders of Lipids and Biochemical Cardiac Markers 69 Examination of Cerebrospinal Fluid 80 Examination of Pleural and Peritoneal Fluids 91 Examination of Sputum 99 Examination of Feces 104 10 Gastric Analysis 121 11 Tests for Malabsorption and Pancreatic Function 127 12 Thyroid Function Tests 137 13 Pregnancy Tests 146 14 Infertility 150 15 Semen Analysis 159 Section Laboratory Hematology 16 Hematopoiesis 169 17 Collection of Blood 179 18 Estimation of Hemoglobin 183 19 Packed Cell Volume 188 20 Total Leukocyte Count 192 21 Reticulocyte Count 196 22 Blood Smear 200 23 Red Cell Indices 213 24 Erythrocyte Sedimentation Rate 215 25 Examination of Bone Marrow 220 26 Diagnosis of Malaria and Other Parasites in Blood 229 27 Laboratory Tests in Anemia 244 28 Laboratory Tests in Hematological Malignancies 273 29 Laboratory Tests in Bleeding Disorders 288 30 Laboratory Tests in Thrombophilia 311 31 Laboratory Tests in Porphyrias 314 32 Automation in Hematology 319 tahir99 - UnitedVRG vip.persianss.ir viii Essentials of Clinical Pathology Section Practical Blood Transfusion 33 34 35 36 37 38 39 Blood Group Systems Blood Grouping Collection of Donor Blood, Processing and Storage Screening Tests for Infections Transmissible by Transfusion Compatibility Test (Cross-match) Adverse Effects of Transfusion Blood Components 329 336 341 347 352 354 359 General References 365 Index 367 tahir99 - UnitedVRG vip.persianss.ir Chemical Pathology and Related Studies tahir99 - UnitedVRG vip.persianss.ir tahir99 - UnitedVRG vip.persianss.ir 16 Hematopoiesis The physiologic process of formation of blood cells is called as hematopoiesis (Greek haima: blood; poiesis: to make) During 3rd week of embryonic life, hematopoiesis begins in the yolk sac, as aggregates of blood cells called as blood islands Around 3rd month of fetal life, some of the hematopoietic stem cells migrate to the liver which then becomes the main site of hematopoiesis Some blood cell formation also occurs in the spleen, lymph nodes, and thymus Bone marrow starts producing blood cells around 4th month of fetal life, and becomes the sole site of hematopoiesis after birth (Box 16.1 and Fig 16.1) In certain conditions, hematopoiesis can become reestablished in liver, spleen, and lymph nodes; this is called as extramedullary hematopoiesis Bone marrow is the soft, gelatinous tissue supported by a reticulin framework that fills the intertrabecular spaces in the cavities of the bones There are two types of bone marrow: red marrow composed of hematopoietic tissue (active marrow) and yellow marrow composed of fat cells (inactive marrow) Active sites of hematopoiesis are: pelvis, vertebra, skull, ribs, sternum, and proximal ends of long bones In children, 100% of the total marrow space is active, while in adults, 50% of total marrow space is active All the blood cells circulating in the peripheral blood are derived from the primitive mesenchymal cells called as pleuripotent hematopoietic stem cells (PHSCs); the Box 16.1: Stages of hematopoiesis • Mesoblastic stage: Begins at 3rd week of gestation; occurs in yolk sac • Hepatic stage: Begins 4-8 weeks of gestation; occurs in liver, thymus, and spleen • Myeloid stage: Begins at 12 weeks of gestation; occurs in cancellous areas of bones Fig 16.1: Sites of hematopoiesis term pleuripotent refers to the ability to produce many cell types Most of the PHSCs are located in the bone marrow, but they are able to enter and circulate freely in peripheral blood Stem cells have the ability of selfrenewal (to maintain a constant pool of undifferentiated cells) and differentiation Hematopoietic stem cells are rare in the bone marrow (1 stem cell per 10000 to 1000000 bone marrow cells) Primitive hematopoietic cells express CD34 antigen Stem cells not have any distinguishing morphological features, and resemble a lymphocyte Stem cells can differentiate along different pathways and produce other tissue cells (stem cell plasticity) Stem cells, as part of their proliferation, become committed to a lineage and are then called as progenitor cells Progenitor cells not have capacity of self-renewal, and have restricted multilineage potential Two multipotential cell lines originate from the pleuripotent hematopoietic stem cell: myeloid and 170 Essentials of Clinical Pathology lymphoid and all blood cells belong to either of these two lineages Myeloid cells include erythrocytes or red cells, platelets, neutrophils, eosinophils, basophils, and monocytes Lymphoid cells are of two main types: B and T lymphocytes The myeloid stem cell is called as CFUGEMM (Colony forming unit granulocyte-erythrocytemonocyte-megakaryocyte) CFU refers to the development of colonies of cells when marrow cells are injected in a tissue culture medium CFU-GEMM leads to the formation of BFU-E (Burst Forming Unit-Erythroid), CFU-Meg (Colony Forming Unit-Megakaryocyte), CFUGM (Colony Forming Unit-Granulocyte-Monocyte/ Macrophage), CFU-Eo (Colony Forming UnitEosinophil), and CFU-Baso (Colony Forming UnitBasophil) CFU-GM further produces CFU-G (Colony Forming Unit-Granulocyte) and CFU-M (Colony Forming Unit-Monocyte/Macrophage) (Fig 16.2) The progenitor cells up to these stages are not identifiable morphologically; they can however be identified by their surface receptors Blood cells in the bone marrow can be considered to be in three compartments or pools: stem cell pool (comprises of pleuripotent and multipotent stem cells, and commited CFUs), proliferating pool (morphologically identifiable precursors that are capable of DNA synthesis and mitosis), and storage pool (maturing and mature cells that are stored for later release in peripheral blood) Hematopoiesis is regulated by two main factors: (i) hematopoietic growth factors (HGFs) or cytokines, secreted by various cell types (Table 16.1), and (ii) stromal cells in the microenvironment of the bone marrow HGFs are glycoproteins secreted by various cell types which regulate proliferation and differentiation of progenitor cells and function of mature blood cells Stromal cells secrete a variety of HGFs in the bone marrow microenvironment; secondly hematopoietic progenitor cells adhere to receptors on stromal cells and on the stromal matrix that facilitates interaction of progenitor cells with regulatory cytokines Fig 16.2: Hierarchy of hematopoiesis Abbreviations: SCF: Stem cell factor; IL: Interleukin; CFU-GEMM: Colony forming unit granulocyte-erythrocyte-monocyte-megakaryocyte; CFU-GM: Colony forming unit granulocyte-macrophage; TPO: Thrombopoietin; CFU- G: Colony forming unit granulocyte; CFU-M: Colony forming unit macrophage; CFU-Eo: Colony-forming unit eosinophil; CFU-Baso: Colony forming unit basophil; CFU-Meg: Colony forming unit megakaryocyte; Epo: Erythropoietin; GM-CSF: granulocyte macrophage colony stimulating factor; G-CSF: Granulocyte colony stimulating factor; M-CSF: Macrophage Colony stimulating factor Hematopoiesis 171 Table 16.1: Hematopoietic growth factors Growth factor Site of synthesis Site of action Granulocyte macrophage colony stimulating factor Granulocyte colony stimulating factor Macrophage colony stimulating factor Erythropoietin Thrombopoietin Stem cell factor Interleukin Interleukin Interleukin T cells, fibroblasts, endothelial cells Monocytes, fibroblasts Granulocytes, monocytes, platelets, red cells Neutrophils Monocytes, endothelial cells, fibroblasts Kidney Liver — T cells T cells T lymphocytes, monocytes, fibroblasts Monocytes Red cells Platelets Pleuripotent stem cells Hematopoietic stem cells Eosinophils B and T cells Fig 16.3: Stages of erythropoiesis Table 16.2: Stages in maturation of red blood cells Cell Size (μ) Nucleus Cytoplasm Proerythroblast 15-20 Blue Early erythroblast (Basophilic) Intermediate erythroblast (Polychromatic) 12-16 Large with immature chromatin, usually a single nucleolus Fine chromatin clumps, nucleolus barely visible Smaller size, chromatin clumps coarse Late erythroblast (Orthochromatic) Reticulocyte (Polychromatic red cell) 8-12 Erythrocyte 12-15 8-10 Small, dense, pyknotic, and eccentric No nucleus 7-8 No nucleus RED BLOOD CELLS Erythropoiesis Stages of erythropoiesis are shown in Figure 16.3 and Table 16.2 Proerythroblast is the earliest morphologically Deep blue due to high RNA Polychromatic due to beginning of hemoglobinization Polychromatic Polychromatic, remnants of RNA visible as a network on supravital staining Pink identifiable erythroid precursor It proliferates to generate sequentially basophilic, polychromatic, and orthochromatic erythroblast; these cells are named after staining characteristics of cytoplasm Reticulocytes still retain some cytoplasmic organelles (a fine reticulim of 172 Essentials of Clinical Pathology ribosomal RNA) With each stage of development, cell size and nuclear size become smaller, chromatin clumping increases, and ultimately nucleus is extruded Color of cytoplasm gradually changes from basophilic to pink due to hemoglobinization A mature red cell or erythrocyte is a biconcave, non-nucleated disk of 7-8 μ size Hemoglobin Hemoglobin (average molecular weight 64,000) consists of heme (iron and protoporphyrin) and globin (two polypeptide chains) A heme group is attached to each polypeptide chain Normally, different types of hemoglobins are present during embryonic life, fetal life, infancy, and adulthood (Table 16.3) Hemoglobin (Hb) Gower I, Hb Gower II, and Hb Portland predominate during embryonic life, while Hb F predominates during fetal life HbF starts to decline after 36 weeks of gestation, and constitutes

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