WHITE CELLS
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

I am active in HealthTap, which provides free medical guidance from your cell phone. There is also a fee site at www.afraidtoask.com.


If you have a Second Life account, please visit my teammates and me at the Medical Examiner's office.

Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

Help me help others

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

PicoSearch
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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
Genes
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Autoimmunity
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Aging
Infections
Nutrition
Environmental Lung Disease
Violence, Accidents, Poisoning
Heart
Vessels
Respiratory
Red Cells
White Cells
Coagulation
Oral Cavity
GI Tract
Liver
Pancreas (including Diabetes)
Kidney

Bladder
Men
Women
Breast
Pituitary
Thyroid
Adrenal and Thymus
Bones
Joints
Muscles
Skin
Nervous System
Eye
Ear
Autopsy
Lab Profiling
Blood Component Therapy
Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Porphyria
Urinalysis
Spinal Fluid
Lab Problem
Quackery
Alternative Medicine (current)
Preventing "F"'s: For Teachers!

Breast / Heme (?!)
Taiwanese pathology site
Good place to go to practice

Hematopathology
Surgical Pathology Atlas
Nice photos, hard-core

Bone Marrow & Lymph Nodes
Photo Library of Pathology
U. of Tokushima

Hematopathology
Brown Digital Pathology
Some nice cases

Lymphomas
U. of Ottawa
Several photos and text

Hematopathology
Photomicrograph collection
In Portuguese

Blood
Iowa Virtual Microscopy
Have fun

Lymphoid

Chaing Mi, Thailand

Lymphoid
Photos, explanations, and quiz
Indiana U.

Bloodline
Category index
Great hematology image collection

Lymph-related organs
Brown Digital Pathology
Some nice cases

Hemepath
Nice photos
UMDNJ

Problems in Bone Marrow Path
Histopathology and essay
For pathologists

Lymph Node Exhibit
Virtual Pathology Museum
University of Connecticut

Hematology Atlas
Nivaldo Medeiros MD
Brazilian Pathologist

Blood 1
Smears
Indiana U.

Blood 2
Photos, explanations, and quiz
Indiana U.

American Society of Hematology (?!)
Image Bank
For the gung-ho students

KCUMB Students
"Big Robbins" -- WBC / Lymph / Spleen
Lectures follow Textbook

QUIZBANK

LEARNING OBJECTIVES

Describe the distribution of lymphoid tissue in humans, with special reference to B- and T-cell zones. Describe the microanatomy of the lymph nodes. Sketch the sequence by which a B-cell develops into a plasma cell, and name each stage.

Distinguish relative and absolute counts of various white cells, and explain why absolute counts are more meaningful. Calculate an absolute count by multiplying the total and percentage counts. Give the healthy absolute counts for lymphocytes, monocytes, eosinophils, and neutrophils.

Given a name of a white cell marker, tell what cell(s) it identifies. Given a white cell type, mention its major markers.

Given a patient with neutropenia and a history, come up with a reasonable differential diagnosis. Describe the typical cause and course of agranulocytosis. Recognize the major causes of lymphopenia.

Give a reasonable differential diagnosis for granulocytosis, eosinophilia, and lymphocytosis. Tell how to distinguish chronic myelogenous leukemia from leukemoid reaction. Describe possible peripheral (i.e., circulating) white cell pictures in sepsis. Mention the significant disease association for increased absolute basophil count.

Describe the important non-neoplastic causes of lymphadenopathy, and how each looks under the microscope. Describe "infectious mononucleosis syndrome", and name its four principal etiologic agents.

Explain how a pathologist distinguishes a malignant lymphoma from a worrisome reactive (benign) lymph node. Do this yourself for an easy case.

Apply the unifying "rules" in this handout to clinical problems about non-Hodgkin's lymphomas. Explain how the classic Rappaport system differs from the International Working system and the Revised European-American system of lymphoma nomenclature. Recognize the names of the low, middle, and high grade lymphomas.

Given the name of a non-Hodgkin's lymphoma, recognize its distinctive features. Identify non-Hodgkin's lymphomas based on their idiosyncratic markers, etiologies, or epidemiologies.

Explain current thinking about the pathogenesis of Hodgkin's disease. Describe its epidemiology, subtypes, and prognosis. Given a description of the background, name the subtype, and vice versa.

Give a short account of the World Health Organization's system of classifying the acute leukemias, and directions that future classifications will probably take. Describe the major kinds of leukemia in detail. Cite their etiologies (if known), pathogenesis, natural histories, subclasses, diagnostic features, and current prognosis. Do the same for the myelodysplastic syndromes, polycythemia vera, and "myelofibrosis with myeloid metaplasia".

Describe the pathogenesis, symptoms, signs, lab findings, diagnosis, typical course, and major complications of plasma cell myeloma. Recognize and prognosticate the other "plasma cell disorders". Recognize the noteworthy causes of polyclonal gammopathy.

Explain current thinking about Langerhans cell histiocytosis (histiocytosis X).

Given an enlarged spleen and the opportunity to ask questions, come up with a reasonable differential diagnosis. Describe the common findings in spleens at autopsy.

Name the lymphoma and/or leukemia caused by with each of these viruses:

    Epstein-Barr virus
    HTLV-I
    HTLV-II
    HIV

Correctly define and use the following terms:

    agranulocytosis
    Auer rod
    Bence-Jones protein
    blast
    bcr/abl oncogene
    chloroma / granulocytic sarcoma / myeloid sarcoma
    cleaved (clefted) lymphocyte
    convoluted lymphocyte
    cryoglobulin
    Dohle body
    gammopathy, monoclonal
    gammopathy, polyclonal
    leukemia
    leukemia, aleukemic
    leukocyte alkaline phosphatase
    leukocytosis
    leukoerythroblastic smear
    leukopenia
    lymphadenopathy
    lymphoma
    M-protein
    myeloid / myelogenous
    myeloma
    neutropenia
    paraprotein
    Pautrier microabscess
    Philadelphia chromosome
    polycythemia (absolute, relative, 1,2)
    pseudolymphoma
    tingible body macrophage
    toxic granulation

Identify the following elements in peripheral and/or marrow smears:

    all five type of normal white cells
    Pelger-Huet anomaly
    circulating blasts
    Auer rods
    teardrop reds

Shown an appropriate peripheral smear, tell when each disease might be present:

    Pelger-Huet anomaly
    acute leukemia (subtype If possible)
    chronic myelogenous leukemia
    chronic lymphocytic leukemia
    hairy cell leukemia
    primary myelofibrosis ("myelofibrosis with myeloid metaplasia", "agnogenic myeloid metaplasia")
    Sézary's syndrome

Identify all the following cells in microscopic sections:

    normal lymphocytes
    small cleaved lymphocytes
    large lymphocytes
    immunoblasts
    normal plasma cells
    normal eosinophils
    classic Reed-Sternberg cells and their major variants

Identify each of the following disease patterns under the microscope:

    follicular hyperplasia
    sinus hyperplasia ("sinus histiocytosis")
    follicular ("nodular") non-Hodgkin's lymphoma
    diffuse non-Hodgkin's lymphoma
    Hodgkin's disease (& subtype If obvious)
    Sézary's syndrome / Mycosis fungoides
    Burkitt's lymphoma
    primary myelofibrosis
    extramedullary hematopoiesis in spleen
    plasma cell myeloma

Draw or recognize a Birbeck granule and describe its significance.

INTRODUCTION

{16282} E-rosette, around a T-cell

{16517} neutrophil, chloroacetate esterase stain

Monocyte

WebPath Photo

Eosinophil and lymphocyte

WebPath Photo

Basophil

WebPath Photo

White Cell Quiz!

WebPath Photo

Lymphocyte and neutrophil

WebPath Photo

Lots of neutrophils

WebPath Photo

Neutrophilia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

NEUTROPENIA: A low absolute neutrophil count in the peripheral blood for any reason. (NOTE: "Leukopenia" is a not-very-useful word that describes any low total white count.)

LEUKOCYTOSIS: It's worth remembering the following NON-NEOPLASTIC CAUSES OF ELEVATED WHITE CELL COUNTS. Most of them make sense:

{13646} Dohle body
{13661} Dohle body
{16213} Dohle body

Hypersegmented poly

WebPath Photo

Hypersegmented poly
Pernicious anemia
KU Collection

LOTS OF EOSINOPHILS (big review Mayo Clin. Proc. 80: 75, 2005; bigger review Arch. Path. Lab. Med. 137: 259, 2013):

{14099} eosinophilic leukocytes (buffy coat)
{09207} eosinophil granule with crystal (electron micrographs; these crystals will combine to form large Charcot-Leyden crystals under some conditions)

Eosinophilia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

LOTS OF MONOCYTES:

LOTS OF LYMPHOCYTES:

Infectious mononucleosis
Blood picture
WebPath Photo

Infectious Mononucleosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

ODD NEUTROPHILS:

{16208} Pelger-Huet, one dose
{16209} Pelger-Huet, one dose
{13658} Pelger-Huet, two doses

Pelger-Huet
Blood picture
WebPath Photo

Pseudo-Pelger Huet
AFIP
Wikimedia Commons

NORMAL LYMPH NODE ANATOMY

Resting small B-lymphocyte

Small cleaved ("clefted", i.e., folded-nucleus) B-lymphocyte

Large cleaved B-lymphocyte

Small non-cleaved B-lymphocyte

[NOTE: This cell is as large as a large cleaved B-lymphocyte]

Large non-cleaved B-lymphocyte

B-immunoblast

Memory B-cells . . and . . Plasma cells

LYMPHADENITIS: Inflammation of the lymph nodes

{36371} toxoplasmosis; many bugs in a cell
{40654} toxoplasmosis; tissue reaction (lame-looking granulomas)

Syphilis in a lymph node

Yutaka Tsutsumi MD

Toxoplasma lymphadenitis

Yutaka Tsutsumi MD

Follicular hyperplasia

WebPath Photo

Follicular hyperplasia

WebPath Photo

Follicular hyperplasia

WebPath Photo

HIV lymphadenopathy

Yutaka Tsutsumi MD

{35609} dermatopathic lymphadenitis (the red-brown is melanin, the white is sebum)

Tuberculous lymphadenitis
Great labels
Romanian Pathology Atlas

Bartonellosis
Cat scratch fever
Yutaka Tsutsumi MD

Subacute necrotizing lymphadenitis
Kikuchi's disease
Yutaka Tsutsumi MD

NON-HODGKIN'S LYMPHOMAS: By definition, monoclonal, malignant tumors of the B- or T-cells, and not of plasma cells, and not Hodgkin's disease. Update Lancet 380: 836 & 848, 2012. By custom, soft tumors of monocytes are included here because they look similar.

Lymphomas and Plasma Cell Neoplasms
"Pathology Outlines"
Nat Pernick MD

CD Markers
"Pathology Outlines"
Nat Pernick MD

Lymphomas
Bryan Lee

Lung lymphoma
Lung pathology series
Dr. Warnock's Collection

FCC lymphoma
Pittsburgh Pathology Cases

B-cell lymphoma
Pittsburgh Pathology Cases

Diffuse large cell lymphoma
Heart
Pittsburgh Pathology Cases

B-cell lymphoma
Large cell
Pittsburgh Pathology Cases

Follicular lymphoma, spleen
AFIP
Wikimedia Commons

{23581} nodular lymphoma

Nodular lymphoma

WebPath Photo

Nodular lymphoma

KU Collection

Lymphoma in lymph node
Invasion of surrounding fat
Tom Demark's Site

{09040} electron micrograph of a malignant lymphoid cell. Note the lack of distinguishing features.

{23575} small lymphocytic lymphoma. There is a small vessel running across the picture. Use the endothelial cell nuclei to gauge the sizes of cells.

{23854} CLL, transforming into a more aggressive cancer. Note the numerous small lymphocytes and the blasts.

Well-differentiated lymphocytic lymphoma
Tom Demark's Site

Waldenstrom's
Pittsburgh Pathology Cases


{13673} heavy chain disease; plasmacytoid cells in intestinal mucosa

{19504} Mediterranean lymphoma, small bowel

{23599} mixed lymphoma; use the endothelial cell at 2:30 as a size marker
{23683} mixed lymphoma

{23596} nodular large-cell; at this power, just appreciate the nodularity
{23581} nodular lymphoma

Large cell lymphoma

WebPath Photo

Large cell lymphoma

WebPath Photo

{23590} diffuse small cleaved lymphoma (all you can tell is that it is small cleaved)
{23593} diffuse small cleaved lymphoma (all you can tell is that it is diffuse)
{46344} diffuse small cleaved lymphoma, marrow

{23581} nodular lymphoma

Small cleaved lymphocyte in blood
Ed Lulo's Pathology Gallery


{08787} large-cell lymphoma
{15389} large-cell lymphoma
{23647} * "angioimmunoblastic lymphadenopathy", a T-cell lymphoma with vascular proliferation that we're not going to worry about -- note the vessels and the monomorphic cell infiltrate)

{23674} true histiocytic lymphoma, trust me

{10935} lymphoma arising in thyroid; my case
{10937} lymphoma arising in thyroid; my case. Notice that the lymphocytes are growing within a follicle.

Body cavity lymphoma and Hodgkin's
Lung pathology series
Dr. Warnock's Collection

Post-transplant lymphoproliferation
Pittsburgh Pathology Cases

Post-Transplant Neoplasia
Great site
Transplant Pathology Internet Services

{00245} immunoblastic lymphoma
{10691} immunoblastic lymphoma, cytology
{10724} immunoblastic lymphoma
{10772} immunoblastic lymphoma
{23623} immunoblastic lymphoma
{23689} immunoblastic lymphoma
{08017} lymphoma in the heart
{11630} lymphoma in the pericardial space
{11633} lymphoma, primary in the heart
{20227} lymphoma, primary in the stomach
{15446} lymphoma, primary in the stomach
{15542} lymphoma, primary in the stomach

{00242} T-lymphoblastic lymphoma. Trust me.

{46189} African Burkitt's
{49035} African Burkitt's

Burkitt's lymphoma
Starry sky
KU Collection

Burkitt's lymphoma
Patient and photomicrograph
KU Collection

Burkitt's
Bryan Lee

Burkitt's
NCI
Wikimedia Commons

Burkitt's after transplant
Pittsburgh Pathology Cases

Burkitt's
Section
Wikimedia Commons

Burkitt's
Smear
Wikimedia Commons


{23620} Burkitt's lymphoma, lipid drops
{46336} Burkitt's lymphoma, lipid drops
{23611} Burkitt's lymphoma, good starry sky
{46332} Burkitt's lymphoma, good starry sky
{23641} * Burkitt's, methyl green pyronine (the red "pyroninophilia" merely tells us that the cytoplasm is rich in ribosomes)
{46326} African Burkitt's, tonsils

{40003} mycosis fungoides
{40004} mycosis fungoides
{12747} mycosis fungoides, plaque phase
{12751} mycosis fungoides
{12754} mycosis fungoides
{13117} mycosis fungoides
{13781} mycosis fungoides
{13784} mycosis fungoides
{24740} mycosis fungoides, histopathology; note Pautrier microabscesses
{12759} mycosis fungoides, Pautrier microabscesses
{13793} mycosis fungoides, Pautrier microabscess
{13796} mycosis fungoides cells in a lymph node (look how wiggly the nuclear membranes are)
{09042} mycosis fungoides cell, electron micrograph

{12757} Sézary patient
{16544} Sézary cell
{23722} Sézary cell
{15409} Sézary cell

{23668} malignant histiocytosis with erythrophagocytosis

Epstein-Barr hemophagocytic syndrome

Yutaka Tsutsumi MD

HODGKIN'S DISEASE ("Hodgkin's lymphoma"; J. Clin. Path. 55: 162, 2002)

{23560} Reed-Sternberg cell
{20057} Reed-Sternberg cell
{36398} Reed-Sternberg cell, not H&E; cytology
{36401} Reed-Sternberg cell, not H&E; cytology
{40423} Reed-Sternberg cell, mitosis

Hodgkin's
Great labels
Romanian Pathology Atlas

Hodgkin's with Reed-Sternberg variants
Great labels
Romanian Pathology Atlas

Hodgkin's Disease ("Hodgkin's granuloma"
is an ancient misnomer.)
Human Pathology Digital Image Gallery

Hodgkin's disease
Nice Reed-Sternberg cell
KU Collection

Hodgkin's, node

WebPath Photo

Hodgkin's, liver

WebPath Photo

Reed-Sternberg cells

WebPath Photo

Reed-Sternberg cell

WebPath Photo

Hodgkin's disease, spleen
AFIP
Wikimedia Commons

Hodgkin's
H&E
Wikimedia Commons

{46338} Lymphocyte predominant Hodgkin's
{46339} Lymphocyte predominant Hodgkin's

{23539} mixed cellularity Hodgkin's disease
{46342} mixed cellularity Hodgkin's disease
{46343} mixed cellularity Hodgkin's disease

{23524} lymphocyte depleted Hodgkin's disease. Just plain anaplastic.

{23542} nodular sclerosing Hodgkin's disease
{23545} nodular sclerosing Hodgkin's disease
{23548} lacunar Reed-Sternberg variants
{23551} lacunar Reed-Sternberg variant

Nodular sclerosing Hodgkin's
Bryan Lee

Nodular sclerosing Hodgkin's

WebPath Photo

Nodular sclerosing Hodgkin's

WebPath Photo

Lacunar cells

WebPath Photo

{20056} Hodgkin's disease in a cervical node (we would of course diagnose this only with microscopy)
{46348} Hodgkin's disease in the spleen
{46349} Hodgkin's disease in the spleen

INTRODUCING THE LEUKEMIAS

Leukemia
Packed marrow
WebPath Photo

Leukemia
Packed marrow
WebPath Photo

Leukemia / myelodysplasia
"Pathology Outlines"
Nat Pernick MD

{23848} packed marrow; * this was late-stage CLL
{36032} packed marrow; * this was AML
{12347} packed marrow; * this was AML

{16243} blast with Auer rods
{29475} lymphoid blasts, pap stain. Big pale nuclei.

M3
AFIP
Wikimedia Commons

Acute promyelocytic leukemia
Good Auer rods
KU Collection

Auer rods

WebPath Photo

{23842} acute lymphocytic leukemia, brain
{08734} acute leukemia, liver; as you would expect, the leukemia is blue
{08735} acute leukemia, liver
{08736} acute leukemia, liver

Acute Lymphoblastic Leukemia
Peripheral smear
KU Collection

{06269} fatal cerebral hemorrhage in leukemia
{01735} brain and dura, acute leukemia

ACUTE LYMPHOBLASTIC LEUKEMIA ("ALL"; diagnosis Am. J. Clin. Path. 111: 467, 1999)

Acute lymphoblastic leukemia
Bone marrow
WebPath Photo

Acute lymphoblastic leukemia
Peripheral smear
WebPath Photo

Acute Lymphoblastic Leukemia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

ALL
Pittsburgh Pathology Cases

{12410} ALL (all you can tell from the smear is "blasts")

{23746} L1
{23833} L1, special stain (cytoplasm is brown)
{23860} L2
{13982} L2, bone marrow
{23758} L3; note the lipid
{13985} L3

ALL-L1
AFIP
Wikimedia Commons

Burkitt's leukemia
Bone marrow
KU Collection

{23857} ALL in the liver
{32027} ALL in the liver
{34513} ALL in the brain
{49316} ALL in the kidney
{49343} ALL in the testis

ACUTE MYELOID LEUKEMIA ("AML", "acute myelogenous leukemia", "poorly differentiated granulocytic leukemia", "acute non-lymphocytic leukemia", "ANLL", etc.; update Lancet 381: 484, 2013 sorts out the molecules)

{12338} AML. Note promyelocyte in center.
{16245} blast, and not much else, M1
{13988} blasts, and not much else, M1
{23830} blast, * chloroacetate-esterase (+), M1
{13940} blast, * chloroacetate-esterase (+), M1
{23839} blast, M1; note nucleolus.
{23770} blasts with a few granules, M2
{13991} blasts with a few granules, M2
{16249} blast with Auer rod, M2
{12344} blast with Auer rod, M2 or maybe M3
{14010} blast with great Auer rods
{23776} blasts with lots of granules, M3
{13994} blasts with lots of granules, M3
{16254} blasts with lots of granules, M3
{10109} blasts with lots of granules, M3
{13997} semi-monocyte like blasts, M4; note indented nucleus and gray cytoplasm
{10133} semi-monocyte like blasts, M4
{13937} non-specific esterase in M4
{23800} monocyte-like blasts in M5
{40449} monocyte-like blasts in M5
{40451} monocyte-like blasts in M5
{23803} non-specific esterase in M5
{14001} monocyte-like blasts in M5
{13928} non-specific esterase in M5
{23949} erythroleukemia, M6. If you don't recognize the malignant cells as red-cell precursors, please check out a histology book.
{14007} erythroleukemia, M6
{16267} erythroleukemia, M6
{23836} erythroleukemia, M6
{23806} erythroleukemia, M6
{16273} erythroleukemia, M6, PAS-positive chunks
{16274} megakaryocytic blasts, M7. See the platelets budding?
{23812} megakaryocytic blasts, M7
{23821} megakaryocytic blasts, M7
{23818} megakaryocytic blasts, PAS-positive, M7
{46340} gingival involvement; this is common in M4 & M5

AML
Pittsburgh Pathology Cases

M2
Pittsburgh Pathology Cases

Acute myeloid leukemia
Tom Demark's Site

M4-Eo
With eosinophils
Wikimedia Commons

M3
AFIP
Wikimedia Commons

M2
AFIP
Wikimedia Commons

M2
AFIP
Wikimedia Commons

Auer rods in blasts
AFIP
Wikimedia Commons

M7 marrow
Tiny megakaryocytes
Wikimedia Commons

M1
AFIP
Wikimedia Commons

M6
AFIP
Wikimedia Commons

M0
AFIP
Wikimedia Commons

M6
Weird normoblasts in circulation
Wikimedia Commons

M5b
AFIP
Wikimedia Commons

M5a
AFIP
Wikimedia Commons

M4
AFIP
Wikimedia Commons

M5 -- electron micrograph
Dented nucleus
Wikimedia Commons

THE MYELODYSPLASTIC SYNDROMES ("THE PRELEUKEMIAS", Carl Sagan's disease): Mayo Clin. Proc. 70: 673, 1995; Am. J. Clin. Path. 119(S1): S-58, 2003.

Myelodysplastic syndrome
Odd megakaryocyte / giant platelet
AFIP

CHRONIC MYELOID LEUKEMIA ("chronic myelogenous leukemia", "well-differentiated granulocytic leukemia"): all about it Lancet 370: 1127, 2007

{10769} CML, splenomegaly
{10763} CML, peripheral blood
{12359} CML
{23863} CML (note the basophil)
{23866} CML, leukocyte alkaline phosphatase stain (black; note the cells are not stained black)

CML, liver
Great labels
Romanian Pathology Atlas

Chronic granulocytic leukemia
Smear
WebPath Photo

Chronic myelogenous leukemia
Peripheral smear
KU Collection

Chronic granulocytic leukemia
Automated profile
WebPath Photo

Chronic granulocytic leukemia
Smear
WebPath Photo

{12371} Philadelphia chromosome

Chronic granulocytic leukemia
Philadelphia chromosome
WebPath Photo

{23869} CML, blast crisis
{12365} CML, blast crisis

"APLASTIC ANEMIA" (updates Ann. Int. Med. 136: 534, 2002; Lancet 365: 1647, 2005; Blood 110: 1603, 2007)

Aplastic anemia

WebPath Photo

CHRONIC LYMPHOCYTIC LEUKEMIA ("CLL", "well-differentiated lymphocytic leukemia"; "the liquid phase of well-differentiated lymphocytic lymphoma", etc.) Lancet 371: 1017, 2008.

CLL / Melanoma
Pittsburgh Pathology Cases

CLL
Pittsburgh Pathology Cases

CLL
Pittsburgh Illustrated Case

CLL and melanoma together in marrow
Pittsburgh Illustrated Case

Chronic lymphocytic leukemia

WebPath Photo

Chronic lymphocytic leukemia
Peripheral smear
KU Collection

Chronic lymphocytic leukemia
Classic drawing
Adami & McCrae, 1914

Chronic Lymphocytic Leukemia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

B-CLL, good smudges
AFIP
Wikimedia Commons

CLL in liver
Great labels
Romanian Pathology Atlas

{08784} CLL
{12389} CLL
{12404} CLL going bad (some blasts)
{12386} CLL with smudges

HAIRY CELL LEUKEMIA (Mayo Clin. Proc. 87: 67, 2012)

{23872} hairy cell leukemia
{10766} hairy cell leukemia, spleen (top; normal at bottom)
{16543} hairy cell leukemia, TRAP stain (red)
{23875} hairy cell leukemia, TRAP stain (red)
{13925} hairy cell leukemia, TRAP stain (red)
{16541} hairy cell leukemia, TRAP stain (red)
{23881} hairy cell leukemia, bone marrow biopsy (trust me)
{42117} big spleen in hairy cell leukemia, foot ruler

Hairy cell leukemia
Peripheral smear
KU Collection

POLYCYTHEMIA VERA ("Osler's polycythemia", "P. V. rubra", etc.; Mayo Clin. Proc. 78: 174, 2003; Arch. Path. Lab. Med. 130: 1126, 2006)

Polycythemia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

PRIMARY MYELOFIBROSIS ("myelofibrosis with myeloid metaplasia"; "agnogenic myeloid metaplasia"; "myelosclerosis"); JAMA 303: 2513, 2010; Mayo Clin. Proc. 87: 25, 2012

{12302} teardrop reds

{13799} myelofibrosis, marrow core biopsy
{24788} myelofibrosis, marrow core biopsy
{13802} myelofibrosis, reticulin stain

PLASMA CELL MYELOMA ("multiple myeloma", "malignant plasmacytoma") NEJM 336: 1657, 1997; Lancet 363: 875, 2004; for pathologists dealing with the difficult diagnostic cases Am. J. Clin. Path. 136: 168, 2011 (let us worry about them).

{08462} bony lesions of myeloma (skull and spine)
{27327} bony lesions of myeloma (skull)
{13769} skull lesions of myeloma
{10760} skull lesions of myeloma
{10754} bone lesions of myeloma
{10757} osteoporosis of myeloma
{46197} femur lesions in myeloma
{46198} rib lesions in myeloma
{27329} spike, probably monoclonal gammopathy of uncertain significance, since normal albumin and gamma seem not to be suppressed

Plasma cell myeloma
Marrow smear
Wikimedia Commons

Plasma cell myeloma
Bone marrow smear
KU Collection

Myeloma skull

WebPath Photo

Myeloma skull

WebPath Photo

Myeloma marrow

WebPath Photo

Myeloma cells, section

WebPath Photo

Myeloma cells, section

WebPath Photo

Myeloma cells, smear

WebPath Photo

{16554} plasma cell myeloma, cells
{16556} plasma cell myeloma, cells
{13772} plasma cell myeloma, marrow aspirate
{27330} plasma cell myeloma, marrow aspirate
{13775} plasma cell myeloma, bone marrow section
{10751} * "grape cell"
{42054} * "flame cell" (named for its staining properties)

{17273} myeloma kidney, Bence-Jones casts with foreign body reaction
{17274} myeloma kidney, Bence-Jones casts with foreign body reaction

OTHER PLASMA-CELL PROBLEMS ("plasma cell dyscrasias", an archaic term)

THE LANGERHANS CELL HISTIOCYTOSIS FAMILY ("LCH", "Histiocytosis X", "disseminated histiocytosis"; * R&F "differentiated histiocytosis" is a typo); review for clinicians J. Ped. 127: 1, 1995; Cancer 85: 2278, 1999.

{09095} Birbeck granules
{09097} Birbeck granules

Histiocytosis X
Pittsburgh Illustrated Case

Histiocytosis X with Birbeck granules
Lung pathology series
Dr. Warnock's Collection

Eosinophilic granuloma of the lung
Lung pathology series
Dr. Warnock's Collection

{23392} Letterer-Siwe disease. Weird histiocytes ("coffee-bean nuclei, even"). Trust me.

{13688} eosinophilic granuloma
{13691} eosinophilic granuloma
{09043} eosinophilic granuloma, EM, coffee-bean nucleus (left) and eosinophil (right)

{10481} Hand-Schüller-Christian disease. Weird histiocytes. Trust me.
{21779} skull in Hand-Schüller-Christian disease

* CHESTER-ERDHEIM DISEASE ("lipid granulomatosis"; "cholesterol granulomatosis") is a rare illness in which lipid-laden non-dendritic-type macrophages infiltrate the tissues. Thankfully rare, it is clonal and seems to be a neoplasm (Hum. Path. 30: 1093, 1999).

THE SPLEEN AND ITS PROBLEMS

* Every man has his own ways of courting the female sex. I should not, myself, choose to do it with photographs of spleens, diseased or otherwise.

        -- Agatha Christie, "The Moving Finger"

Normal spleen

WebPath Photo

Big spleen
Briish
ITP case

{00239} Gaucher's disease, spleen
{09864} Gaucher's disease, spleen
{16216} Gaucher's disease, watered-silk ("wadded kleenex") cell from spleen


Big spleen
From a cirrhotic
WebPath Photo

Reed-Sternberg cells

WebPath Photo

Big spleen
Some myeloproliferative disorder
WebPath Photo

Splenomegaly
Urbana Atlas of Pathology

Infarcts

WebPath Photo

You remember the difference between sections and smears, right?

* SLICE OF LIFE REVIEW: BLOOD CELLS

10110 ff blood

{10766} leukemia, hairy cell and normal
{12275} anemia, iron deficiency; normal
{13715} lymphocyte, normal
{13868} red blood cell, normal blood
{13910} red blood cell, normal
{14702} polymorphonuclear leukocyte, normal
{14703} polymorphonuclear leukocyte, normal
{14704} polymorphonuclear leukocyte, normal
{14705} polymorphonuclear leukocyte, normal
{14705} polymorphonuclear leukocyte, normal
{14706} polymorphonuclear leukocyte, normal
{14707} polymorphonuclear leukocyte, normal
{14708} eosinophil, normal
{14709} eosinophil, normal
{14710} basophil, normal
{14711} basophil, normal
{14712} monocyte, normal
{14713} monocyte, normal
{14714} monocyte, normal
{14715} monocyte, normal
{14716} lymphocyte, large
{14717} lymphocyte, large
{14718} lymphocyte, normal
{14719} lymphocyte, normal
{14720} lymphocyte, normal
{14721} lymphocyte, normal
{14722} reticulocytes, normal
{14723} reticulocytes, normal
{14724} red blood cell, abnormal
{14725} red blood cell, abnormal
{14726} platelets, normal
{14727} platelets, normal
{14728} pronormoblast, normal
{14729} pronormoblast, normal
{14730} basophilic normoblast, normal
{14731} basophilic normoblast, normal
{14732} normoblast
{14733} normoblast
{14734} polymorphonuclear leukocyte & * lymphocyte
{14735} polymorphonuclear leukocyte & * lymphocyte
{14736} normoblast series
{14737} normoblast series labelled
{14738} myelocyte, normal
{14739} myelocyte, normal
{14740} * granulocyte series
{14741} * granulocyte series (labelled)
{14742} myelocyte, band form
{14743} myelocyte, band form
{14744} myelocyte, normal
{14745} myelocyte, normal
{14746} myelocyte, normal
{14747} myelocyte, normal
{14748} myelocyte, normal
{14749} myelocyte, normal
{14750} myelocyte, normal
{14751} myelocyte & megakaryocyte, normal
{14752} myelocyte & megakaryocyte, normal
{15193} plasma cell, #23
{15205} thymus, adult
{15564} thymus, normal
{15565} thymus, normal
{15566} thymus, normal
{15567} thymus, normal
{16175} red blood cell, normal
{20782} polymorphonuclear leukocyte, normal
{20783} monocyte
{20784} platelets, circulating blood
{20785} monocyte
{26230} polymorphonuclear leukocyte, normal
{40179} thymus, normal
{46538} red cell, normal

* SLICE OF LIFE REVIEW: LYMPHOID ORGANS
{11750} spleen, normal
{11751} spleen, normal
{11753} lymph node, normal
{11797} spleen, normal
{11805} spleen, normal unfixed
{14753} thymus, human fetal
{14754} thymus, human fetal
{14755} thymus, juvenile
{14756} thymus, juvenile
{14757} thymus, adult
{14758} thymus, adult
{14759} thymus, juvenile
{14760} thymus, juvenile
{14761} hassall's corpuscles
{14762} hassall's corpuscles
{14763} hassall's corpuscles
{14764} hassall's corpuscles
{14765} thymus (septum)
{14766} thymus (septum)
{14767} spleen, normal
{14768} spleen, normal
{14769} spleen, pulp
{14770} spleen, pulp
{14771} spleen (trabeculae), normal
{14772} spleen (trabeculae), normal
{14773} spleen (trabecular artery), normal
{14774} spleen (germinal center), normal
{14775} spleen (germinal center), normal
{14776} spleen (venous sinus), normal
{14777} spleen (venous sinus), normal
{14778} spleen (scanning em)
{14779} spleen (scanning em)
{14780} lymph node, normal
{14781} lymph node, normal
{14782} lymph node cortex, normal
{14783} lymph node cortex, normal
{14784} lymph node, medulla
{14785} lymph node, medulla
{14786} lymph node, normal
{14787} lymph node, normal
{15189} lymph node and subcapsular sinus, #23
{15190} lymph node, primary nodule
{15191} lymph node, germinal center
{15192} lymph node, medulla
{15194} spleen, #24
{15195} spleen, * red pulp and white pulp
{15196} spleen, central artery
{15197} spleen, central artery and germinal cent
{15198} spleen, trabeculae
{15199} thymus, #25
{15200} thymus, cortex
{15201} thymus, hassall's corpuscle
{15202} thymus, medulla
{15203} thymus, epithelial reticular cell
{15568} spleen, normal
{15569} spleen, normal
{15570} spleen, normal
{15571} spleen, normal
{15769} spleen, normal
{15770} spleen, normal
{20200} spleen, normal
{20799} lymph node, overview
{20800} lymph node, cortex
{20801} lymph node, medulla
{20802} lymph node, subcapsular sinus
{20803} lymph node, secondary nodule
{20804} lymph node, primary nodule
{20805} spleen, normal histology
{20806} spleen, red pulp
{20807} spleen, white pulp
{20808} spleen, central artery
{20809} spleen, red pulp
{20810} spleen, secondary nodule
{20811} spleen, trabecula
{20812} thymus, overview
{20813} thymus, medulla
{20814} thymus, cortex
{20815} thymus, hassall's corpuscle
{20827} tonsil, palatine
{20828} tonsil, pharyngeal
{24782} lymph node, normal
{24783} lymph node, normal
{36344} lymph node, normal
{36347} lymph node, normal
{36350} lymph node, normal cytology
{36353} lymph node, normal cytology

BIBLIOGRAPHY / FURTHER READING

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