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Hematopoiesis: Q

  1. 3rd week of Intrauterine life - Yolk sac
  2. By 3rd month - Stem cells migrate to liver. Chief source of blood formation until shortly before birth.
  3. 4th  Month - Stem cells migrate to bone marrow
  4. By Birth - Marrow throughout the skeleton is hematopoietically active and chief source of blood cells
  5. Upto puberty Q Marrow throughout skeleton red and hematopoietically active.
  6. By 18 years of aged - Red marrow only in flat bones.
Embryonic Hemoglobin
A) Gower1--- 2 zeta 2 epsilon
B) Gower 2---- 2 alpha and 2epsilon
C) Portland ---- 2 zeta 2 gamma
Significant Switchover Time from fetal Hb to adult HB                               
  1. Starts ---30 weeks   
  2. Completed by -38 weeks
Hemoglobin Synthesis -----FIRST appears at proerythroblast (Pronormoblast)

Howell Jolly -- nuclear remnants madeup of DNA


Bone marrow:

  • Provides unique microenvironment for the orderly proliferation, differentiation, and release of
  • blood cells.
  • Bone marrow aspiration and bone marrow biopsy provide information about bone marrow.
  • Ratio of fat cells to hemopoietic cells in an adult is 1:1. Q
  • Normal marrow has 65% granulocytes and their precursor; 25% erythroid precursors and 10% lymphocytes, monocytes and their precursors. Normal M:E ratio 2 to 3:1
  • Maximum number of myeloid cells are myelocytes metamyelocytes and granulocytes.
  • In erythroid compartment, polychromatophilic and orthochromatic normoblasts are maximum. 

Table : Adult reference Ranges for Red Blood Cells.

Measurement (units) Men Women
Hemoglobin (gm/dL) 13.6 – 17.2 12.0 –15.0
Hematocrit (%) 39-49 33-43
Red cell count (106/µL) 4.3-5.9 3.5-5.0
Reticulocyte count (%) 0.5-1.5 0.5-1.5
Mean cell volume (MCV) (µm3)   82-96
Mean corpuscular hemoglobin (MCH) (pg) 27-33) 28-32
MCHC (gm/dL) 32- 36 32 – 36


Erythrocyte Sedimentation Rate (ESR)

  • Sedimentation rate or Westergren ESR.
  • Is the rate at which red blood cells sediment in a period of one hour (mm/h).
  • Non-specific measure of inflammation.
  • ESR best measured by automated analyzers
  • ESR is controlled by balance between pro-sedimentation factors (fibrinogen) and factors resisting sedimentation (negative charge of the erythrocytes ----zeta potential ).
  • During inflammation high fibrinogen causes red blood cell sticking red cells form stacks called 'rouleaux,' which settle faster.
  • Basal ESR is slightly higher in females.
  • Normal Level:
  1. Adults (Westergren method):
    1. Under 50 years--- less than 15 mm/hr
    2. Over 50 years---- less than 20 mm/hr


  1. Under 50 years--- less than 20 mm/hr
  2. Over 50 years--- less than 30 mm/hr
  1. Children (Westergren method):
  • Newborn---- 0 to 2 mm/hr
  • Newborn to puberty---- 3 to 13 mm/hr
Increased :-
  • Pregnancy,                                        
  • Inflammation,                  
  • Anemia;                                             
  • Rheumatoid arthritis,                      
  • Renal cell cancer.            
  • Allergic vasculitis;
  • Giant cell arteritis;                          
  • Hyperfibrinogenemia (increased fibrinogen levels in the blood);
  • Necrotizing vasculitis                        
  • Polymyalgia rheumatica
  • Polycythemia,                  
  • sickle cell anemia,                                                            
  • Hereditary spherocytosis,
  • Congestive heart failure.
  • Hypofibrinogenemia (decreased fibrinogen levels)  
C-Reactive Protein (CRP)
  • So named because it was first detected in serum of patients with acute inflammation with the C-polysaccharide of Pneumococcus.
  • It is not related to C-peptide or protein C.
  • Blood protein which rise in response to inflammation (i.e. C-reactive protein is an acute-phase protein).
  • Its physiological role is to bind to phosphocholine expressed on surface of dead or dying cells (and some types of bacteria) in order to activate the complement system via the C1Q complex.
  • CRP is synthesized by the liver
  • It is member of pentraxin family of proteins.
  • C-reactive protein was the first pattern recognition receptor (PRR) to be identified.
  • CRP gene is located on chromosome 1q.
  • Normal concentration
    Less than 10 mg/L (slightly increasing with aging).
  • Biochemistry of C-Reactive Protein in inflammation.
  1. Increases after.--4-6.hrs
  2. Reaches a peak value in--- 24 hrs.
  3. Remains elevated for---48 hrs ...
  4. level of 10 mg/L has consistently been shown to be the most reliable cut-off to indicate sepsis.
  5. (CRP < 10 mg/L is normal)
  • In late pregnant women,
  • Mild inflammation and
  • Viral infections
  • Active inflammation
  • Bacterial infection
  • Burns

- CRP is more sensitive and accurate reflection of the acute phase response than ESR.
- The half-life of CRP is constant.(Half life is ---less than 24 hrs)
- CRP returns to normal more quickly than ESR in response to therapy.

  • (Highly sensitive) hs-CRP
    • Used as a very rough proxy for heart disease risk.
    • Not a very specific prognostic indicator
    • Risk groups defined as :-
  1. Low Risk---- less than 1.0 mg/L
  2. Average risk---1.0 to 3.0 mg/L
  3. High risk----- above 3.0 mg/L
    hs-CRP is not used alone and it should be combined with elevated levels of cholesterol, LDL-C, triglycerides, and glucose level
  • Normal CRP with increase ESR ---active /untreated polymyalgia rheumatica (giant cell arteritis) CRP is normal but ESR increased. Levels of CRP may not be increased in people with rheumatoid arthritis and lupus.
  • Hypoproteinemia with preservation of A/G ratio is seen in protein-losing enteropathy.

For reticulocytes --

  1. Romanowsky stain (non specific).
  2. Specific: 
    1. best, brilliant cresyl blue.
    2. New methylene blue

Hemoglobin Estimation Methods:

  1. Cyanmethaemoglobin method (best method)
  2. Oxyhemoglobin method
  3. Alkaline hematin method
  1. Reticulocytes
    1. Reticulocytes are large red cells (macrocytic cells) that are spherical and have a bluish color (polychromasia) due to free ribosomal RNA.
    2. Reticulocytes do not have nucleus, note that are RBC with a nucleus (nRBC) in peripheral blood is abnormal
    3. Maturation into mature RBC takes about 1 day.
    4. Reticulocyte count: percent of- reticulocytes  present in peripheral blood.Q
      This is the absolute number of red blood cells present
      (normal =0.5 to 2.5%)
      1. Corrected reticulocyte count (patient's hct/45) x reticulocyte count
        1. Corrects for degree of anemia
        2. < 2% : poor bone marrow response: > 3%: good bone marrow response
      2. Reticulocyte index: corrected reticulocyte count /2
  1. Use if bone marrow reticulocytes (shift cells) are present (polychromasia)
  2. Divide by 2 because shift cells take twice as long as reticulocytes to mature
  3. Blood index which reflects iron deficiency more accurately—MCV
  1. Classification of anemia based on color
  1. Norm chromic; normal color (central pallor of about a third the diameter of the RBC)
  2. Hypo chromic: decreased color (seen as increased central pallor of RBC)              .
  3. Hyper chromic: increased color (loss of central pallor of RBC) eg macrocytes, spherocytes
  1. Pathogenesis of anemia Q
  1. Blood loss
  2. Hemolytic anemia
  3. Impaired RBC production

Table: Common Red Cell Appearances And Their Causes

  1. Microcytosis (Reduced average cell size, MCV < 76 fl)        
    1. Iron deficiency         
    2. Sideroblastic anaemia   
    3. Thalassemia   
    4. Lead toxicity     
    5. AOCD(+/-)         
  2. Macrocytosis (increased average cell size, MCV > 100 fl)
    1. Vitamin B12/Folate deficiency              
    2. Hypothyroidism, Thiamine deficiency
    3. Liver disease, alcohol                              
    4. ​Drugs (e.g Zidovudine)
  3. Normocytic with high reticulocyte count
    1. Blood Loss                                                
    2. DIC  
    3. Hemolytic anemia                                  
    4. Sickle cell anemia      
    5. ​Hemangioma
  4. Normocytic with low reticulocyte count
    1. RBC aplasia (Diamond Black fan syndrome, Parvo virus)
    2. Malignancy                                              
    3. Fanconi Anemia              
    4. AOCD              
    5. CRF
  5. Target cells (Central area of haemoglobinisation)
    1. Liver disease                                            
    2. Post – splenectomy   
    3. Thalassanemia                                        
    4. Hemoglobin C disease
  6. Spherocytes (dense cells, no area of central pallor)
    1. Autoimmune hemolysis                        
    2. Hereditary spherocytosis              
    3. ​Post – splenectomy
  7. Red cell fragments Micro angiopathic hemolytic anemia.
    1. DIC                                          
    2. HUS                                    
    3. TTP
  8. Nucleated Red` blood cells (Normoblasts)
    1. Marrow infiltration                                
    2. Myelofibrosis                  
    3. Severe hemolysis  
    4. Acute hemorrhage
  9. Howell – Jolly bodies (small round nuclear remnants)
    1. Hyposplenism                                        
    2. Dyshemopoiesis              
    3. Post – splenectomy
  10. Polychromasia (young red cells – reticulocytes present)
    1. Hemolysis                                
    2. Acute hemorrhage          
    3. Increased Red cell turnover
  11. Basophilic stippling (abnormal ribosomes appear as blue dots)
    1. Dyshemopoiesis                                      
    2. Lead poisoning .         
  12. Lead poisoning can Causes
    1. Sideroblastic anemia                            
    2. Hemolysis                          
    3. ​Punctate Basophilia
Inclusion Bodies

Definition-Anemia may be defined as a state in which the blood hemoglobin level is below the normal range for the patient’s age and sex
(Males < 13gm/dL; females < 12 gm/dL. (Pregnancy <11 gm%)
Hemoglobin at birth is about 20 gm/dl and it gets reduced to 10 gm/dl at 3 months of age.

Important Points: Symptoms and Signs

  1. Fatigue,                          
  2. breathlessness on exertion,          
  3. palpitation,                                     
  4. angina,
  5. tachycardia,              
  6. cardiac dilatation,                         
  7. systolic flow murmurs,                
  8. edema. 

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