6. MUST to KNOW in Hematology

Hematology EDTA (Lavender top)

Modified Westergren ESR (Black top tube) Citrate (Light blue top tube)

Polycythemic patients

Oxalate Heparin

Order of Draw (Henry 21st Edition)

Order of Draw (Syringe method)

MUST TO KNOW IN HEMATOLOGY Greek: -Haima = Blood -Logos = Study/science Chelates calcium Inversion: 8x Anticoagulant of choice for hematology cell counts and cell morphology Blood smear: prepare w/in 2 hrs Preferred anticoagulant for platelet count: = In some patients w/ EDTA anticoagulated blood – platelet satellitism = Platelet satellitism: platelets adhere to neutrophils ♫ Effect to automated platelet count  Decreased ♫ Remedy: Repeat platelet count using citrate (Rodak: Platelet count x 1.1)  EDTA = Shrinkage of cells =  Hct =  ESR Not for coagulation tests: = Inhibits fibrinogen-thrombin reaction = Factor V is not stable in EDTA 2mL EDTA + 0.5mL NSS/Citrate Ratio = 1:4 (Anticoagulant-to-Blood) For coagulation and platelet studies = Preserves labile factors V and VIII = Buffered 3.2% (0.109M) citrate Inversion: 3-4x Ratio = 1:9 (Anticoagulant-to-Blood)  Hct  Excess Citrate =  PT,  APTT Remedy: Reduce the volume of citrate Amount of citrate = [(100-Hct)÷(595-Hct)] x mL WB Double/balanced oxalate (Ratio = 2:3): Maintained cell structures a. Potassium oxalate (Paul-Heller’s) = shrink cells b. Ammonium oxalate (Wintrobe’s) = swell cells Inactivation of thrombin Anticoagulant for osmotic fragility test Inversion: 3-4x Not for blood film preparation: = Distorts cells = Produces bluish background on Romanowsky’s stain Not for coagulation = Inhibits thrombin and all stages of coagulation Evacuated tube: 1. Sterile blood culture tube 2. Citrate (blue) 3. Nonadditive tube (red) 4. Heparin (green) 5. EDTA (lavender) 6. Fluoride (gray) 1. EDTA 2. Other anticoagulated tubes 3. Nonadditive tube Page | 177

EDTA containing tubes

Skin puncture

Venipuncture

Common gauge (needle) Common length of needle Color coded hub (gauge)

Angle Tourniquet BP cuff as tourniquet Reassure the patient Position the patient IV line

Hematopoiesis Mesoblastic period

Hepatic period

Lavender Pink White Royal blue Tan 1. Fingertips 2. Earlobe: less admixture w/ tissue juice, less pain, less free nerve endings 3. Lateral portion of the plantar surface of the foot: 9 μm) Microcytes ( Anode) C > S > F > A1 > Barts > I > H E D O G A2 Lepore Normal: HbA1 is the fastest (most anodal) Abnormal: HbH is the fastest (most anodal) Acid pH: 6.0-6.3 Migration: (Cathode > Anode) F > A |Origin| O > S > C E D G 1. Sodium metabisulfite = (+) Sickling of cells 2. Solubility test = Sodium thiosulfite = (+) Turbidity  in β-thalassemia Quantitation: Anion exchange microchromatography Alkali resistant (+) HiCN Tests: 1. Alkali denaturation test = HbF resists alkali denaturation a. Betke (NaOH) b. Singer (KOH) 2. Acid elution test = HbF resists acid-elution = Cells w/ HbF = deep pink color = Cells w/ N-HbF = ghost cells 1. Heat precipitation test: Δ50’C for 2 hrs 2. Isopropanol precipitation test: 17% solution Sample Criteria for Erythrocyte Morphology Evaluation w/in Normal 1+ 2+ 3+ Limits (OIO) (per OIO) (per OIO) (per OIO) 0-5 5-10 10-20 20-50 0-5 5-10 10-20 20-50 0-2 3-10 10-50 50-75 0-2 3-10 10-20 20-50 -1-5 6-10 >10 Numerous -Agg. of 3-4 RBCs Agg. of 5-10 RBCs aggregates

4+ (per OIO) >50 >50 >75 >50 ---

Nuclear Abnormalities Hyposegmentation (neutrophil) Bilobed nucleus: Dumb-bell shaped/spectacle/peanut-shaped/”Pince-nez” Page | 190

Hypersegmentation

Alder-Reilly granules

Toxic granules Toxic vacuoles Auer rods Faggot cells Chediak-Higashi granules

May-Hegglin inclusion

Dohle bodies Dohle-Amato bodies

IT: Infections, Toxic states

Job’s syndrome Lazy leukocyte syndrome Chronic Granulomatous Disease (CGD)

Resembles Stab cell (To differentiate: PH cell has more clumped chromatin) ♫ Pelger-Huet anomaly = Autosomal Dominant ♫ Pseudo-Pelger-Huet = Acquired in myeloproliferative disorders ≥ 6 lobes (neutrophil) Abnormal DNA synthesis ♫ Undritz anomaly = hereditary hypersegmentation ♫ Megaloblastic anemia Cytoplasmic Abnormalities Large purple-black coarse cytoplasmic granules Accumulation of degraded mucopolysaccharides (all leukocytes) ♫ Alder-Reilly anomaly = Autosomal Recessive ♫ Mucopolysaccharidoses: Hurler, Hunter, Sanfilippo syndrome Resemble toxic granules (IT) Large purple to black granules resembling ALR granules ♫ Infections ♫ Toxic states Infections Toxic states Pink or red rod shaped structures Fused primary granules (peroxidase positive) Myeloid and monocytic series only w/ mass of Auer rods M3 (APL) = associated w/ DIC Giant red, blue to grayish round inclusions (large lysosomal granules) Seen in lymphocyte, neutrophil and monocyte Lysosomal defects Platelets lack dense granules ♫ Chediak-Higashi syndrome = Autosomal Recessive (Albinism) Pale blue inclusions derived from RNA ♫ May-Hegglin anomaly = Autosomal Recessive = Giant platelets = Thrombocytopenia Resemble Dohle bodies (IT) Single or multiple blue inclusions Aggregates of free ribosomes of rough ER Resembles ♫ Infections ♫ Toxic states Dohle bodies Toxic granules Toxic vacuoles Abnormalities in Function Normal random activity Abnormal chemotactic activity Abnormal random and chemotactic activity Inability of phagocytes to kill ingested microorganisms Impaired NADPH oxidase Impaired oxidative metabolism/respiratory burst Page | 191

LE cell

Tart cell

Test: NBT dye test Cells Exhibiting Phagocytosis Neutrophil w/ large purple homogeneous round inclusion Believe to be a neutrophil that ingested another neutrophil Buffy coat Smooth and evenly stained ♫ SLE Monocyte w/ ingested lymphocyte Rough and unevenly stained

Abnormalities Involving Lymphocytes a. Type I = Turk’s irritation cell = Plasmacytoid lymphocyte w/ large block of chromatin b. Type II = Infectious mononucleosis: caused by EBV (target: B cells [CD21]) = Atypical lymphocyte in IM: T cells reacting to B cells infected w/ EBV c. Type III = Vacuolated = Swiss cheese/moth eaten appearance Basket cell Lymphocyte w/ thumbprint appearance Smudge cell ♫ Due to pressure in smear preparation  Automated cell count ♫ Remedy: Add bovine albumin ♫ CLL Hairy cells B cells w/ hair-like projection ♫ Hairy cell leukemia = TRAP (+) Sezary cells w/ cerebriform nucleus (“brain-like”) ♫ Sezary syndrome ♫ Mycosis fungoides Abnormalities Involving Monocytes/Macrophages/Histiocytes (Lipidoses/Lipid Storage Diseases) Gaucher’s disease Accumulation of glucocerebroside (-) glucocerebrosidase/β-glucosidase Wrinkled/crumpled cytoplasm (Chicken scratch) Niemann-Pick disease Accumulation of sphingomyelin (-) sphingomyelinase Foamy cytoplasm Foam cells w/ sphingomyelin Tay Sach’s disease Accumulation of glycolipid and ganglioside (-) Hexosaminidase A Vacuolated cytoplasm Sandhoff’s disease Accumulation of glycolipid and ganglioside (-) Hexosaminidase A & B Vacuolated cytoplasm Sea blue histiocytosis Unknown enzyme deficiency Blue-green cytoplasm Abnormalities Associated w/ Plasma Cells Flame cell Plasma cell w/ red to pink cytoplasm Page | 192 Reactive lymphocyte Atypical lymphocyte Stimulated lymphocyte Variant lymphocyte Downey cell

Grape cell Mott cell Morula cell Berry cell Russell bodies Dutcher’s bodies Giant platelet Small/micromegakaryocyte Large megakaryocyte Mononuclear megakaryocyte Vacuolated megakaryocyte Leukemia

Acute leukemia Subacute leukemia Chronic leukemia Leukemic leukemia Subleukemic leukemia Aleukemic leukemia French-American-British (FAB) Classification of Acute Leukemias Acute leukemia Acute leukemia in children Tests to differentiate ALL from ANLL

♫ Multiple myeloma of IgA origin Plasma cell w/ vacuoles Accumulation of Russell bodies ♫ Multiple myeloma Individual globules of immunoglobulin Intranuclear protein inclusions Platelet Abnormalities (Morphologic) ♫ Bernard-Soulier syndrome ♫ May-Hegglin anomaly ♫ Myelodysplastic syndromes

Leukemia Abnormal, uncontrolled proliferation and accumulation of one or more of the hematopoietic cells Symptoms: Fever, weight loss,  sweating; hepatosplenomegaly, enlarged lymph nodes (chronic leukemia)  BMR Days to 6 months Predominantly immature cells (blasts and “pro” stages) 2 to 6 months Variable Minimum of 1 or 2 years Predominantly mature cells WBC >15,000/μL WBC 10% granulocytic cells Acute promyelocytic leukemia (APL) >30% blasts >10% granulocytic cells >30% or >50% promyelocytes (+) Faggot cells = Associated w/ DIC Acute myelomonocytic leukemia (AMML) Naegeli’s leukemia 20% to 80% monocytic cells (>80% monoblasts) Acute monoblastic leukemia w/ maturation >80% monocytic cells (30% blasts >50% erythrocytic precursors Acute megakaryocytic leukemia >30% blasts >30% megakaryocytic cells Chronic Myeloproliferative Disorders Proliferation of abnormal pluripotential stem cell Stem cell differentiates into the granulocytic (myeloid stem cell), megakaryocytic and erythroid cell lines (+) Philadelphia chromosome: t(9+;22-) - both long arms If (-) Ph’ chromosome = poor prognosis Similar to leukomoid reaction, to differentiate: a. Chromosome studies b. LAP = ( in Leukomoid reaction,  in CML)

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2. Myelofibrosis w/ myeloid metaplasia (MMM)

Fibrosis and granulocytic hyperplasia of BM, w/ granulocytic and megakaryocytic proliferation in the liver and spleen (extramedullary) (+) Dacryocytes  LAP BM aspirate = impossible (dry tap) BM biopsy = appropriate 3. Essential Thrombocytosis: 1,000 x 109/L Thrombocythemia (ET) Functionally abnormal platelets 4. Polycythemia Vera (PV) BM: Panmyelosis PB: Pancytosis/Pancythemia RBCs, WBCs, Plts  LAP (Other polycythemia: N-LAP) Polycythemia 1’ Absolute polycythemia Other names: Polycythemia Vera, Polycythemia Rubravera, Vaquez Osler disease, Panmyelosis  RBC mass ( Hct)  RBCs,  WBCs,  Platelets  Erythropoietin (EPO) 2’ Absolute polycythemia In response to hypoxia w/ appropriate production In patients w/ pulmonary/cardiac disease of EPO  RBCs,  WBCs,  Platelets  EPO 2’ Absolute polycythemia In patients w/ tumors of kidney, liver, brain, adrenal and pituitary gland w/ inappropriate  RBCs, N-WBCs, N-Platelets production of EPO  EPO Relative polycythemia Spurious/Gaisboö ck polycythemia Associated w/ stress and anxiety N-RBC mass  Hct because of decreased plasma volume RBC mass Differentiate absolute from relative polycythemia  RBC mass = Absolute polycythemia N-RBC mass = Relative polycythemia Myelodysplastic Syndrome/Dysmyelopoietic Syndrome MDS Clonal abnormalities in hematopoietic cells “Pre-leukemia”: can progress to ANLL if not treated Common thromboplastin/Prothrombinase (Va-Xa-Ca2+-PL) II ---(Prothrombinase)---> Thrombin I ---(Thrombin)---> Fibrin clot XIII---(Thrombin)---> XIIIa Fibrin clot ---(XIIIa)---> Stable fibrin clot Most concentrated Involved in all stages of coagulation except contact phase Page | 204

Contact group

XII, XI, PK, HMWK Ca2+ independent Vit. K independent Involved in the contact phase XII ---(Collagen)---> XIIa (small amount) PK ---(XIIa)--------> Kallikrein XII ---(Kallikrein+HMWK)---> XIIa (large amount) XI ---(XIIa)---------> XIa Fibrinogen group I, V, VIII, XIII Ca2+ dependent Vit. K independent Completely consumed during coagulation (+) in plasma (-) in serum Prothrombin group II, VII, IX, X Ca2+ and Vit. K dependent First: VII  IX  X  II: Last Adsorbable factors: removed by adsorbing agents [BaSO4, Al(OH)3] (+) in plasma (-) in serum Diseases BT PT APTT Stypven TT Duckert’s  Disease of 1’ hemostasis N N N N N     Fibrinogen deficiency N* N    Prothrombin deficiency N N N    Parahemophilia N N N  Factor VII deficiency N N N N N  Hemophilia A N N N N N   von Willebrand disease N N N N  Hemophilia B N N N N N    Factor X deficiency N N N  Hemophilia C N N N N N  Factor XII deficiency N N N N N Factor XIII deficiency N N N N N Abn      DIC Abn *BT may be prolonged in afibrinogenemia Adsorbed Fresh Plasma Aged Plasma Fresh Serum Aged Serum Plasma I + + + II + + + ( 3

RPI < 2 Miller disk Eosinophil count Eosinophilia

Eosinopenia Eosinophil diluting fluids

Brucellosis Tuberculosis Monocytic leukemia SBE Typhoid Rickettsial infections Collagen disease Hodgkin’s disease Gaucher’s disease (+) immature granulocytic cells Leukemia Bacterial infections Hypersegmented neutrophils (≥6 lobes) NV: Adult = 0.5-1.5% (Ave: 1.0%) Newborn = 2-6% [# Retics ÷ # RBC (1000)] x 100 ARC = (% Retics ÷ 100) x RBC count (1012/L) x 1,000 NV = 25-75 x 109/L CRC = % Retics x (Patient Hct ÷ Normal Hct [0.45L/L]) NV = 1 General indicator of the rate of erythrocyte production increase above normal in anemias Indicates BM response to anemia RPI = CRC ÷ Maturation time of retics in the blood NV = 1 (Hct: 45%) 1.0 day = Hct: 45 ± 5% 1.5 days = Hct: 35 ± 5% 2.0 days = Hct: 25 ± 5% 2.5 days = Hct: 15 ± 5% Adequate response of BM to anemia - Chronic hemolysis - Recent hemorrhage - Response to therapy Inadequate response of BM to anemia - Aplastic anemia - Ineffective erythropoiesis (megaloblastic anemia) % Retics = Retics (A) ÷ [RBC (B) x 9] x 100 NV = 50-350 x 106/L Allergic reactions Parasitic infections Brucellosis Leukemias Hyperadrenalism (Cushing’s disease) Shock Administration of ACTH Composition: a. Phloxine/eosin/neutral red iodide = stains eosinophils Page | 216

Thorn’s test

RBC indices MCV MCH MCHC Defective centrifuge

MCHC >38% does not occur MCHC will not fall 2 (lower by 50%) Abnormal: Eo. count: 1 = 2 (hypoadrenalism) Erythrocyte Indices (Wintrobe Indices) Classify anemia according to RBC morphology MCV = (Hct ÷ RBC) x 10 NV = 80-100 fL (old: μm3) MCH = (Hgb ÷ RBC) x 10 NV = 27-32 pg (old: μμg) Rarely used MCHC = (Hgb ÷ Hct) x 100 NV = 31-36% (31-36 g/dL) Values affected: = Hct = MCV = MCHC Incorrect calculation (+) cold agglutinins Lipemia (+) HbS & HbC Erythrocyte Sedimentation Rate (ESR) Nonspecific measurement used to detect & monitor an inflammatory response to tissue injury Erythrocytes: *Macrocytes *Anemia Plasma composition: most important determinant *Fibrinogen *α1-globulin *α2-globulin *β-globulin *γ-globulin *Cholesterol Technical factor: *Tilting = 30 angle = 30% error *Temp. Erythrocytes: *Microcytes Page | 217

Stages of ESR

Wintrobe & Landsberg

Standard/Original Westergren

Modified Westergren Zeta Sedimentation Ratio (ZSR) Erythrocyte Osmotic Fragility test (Griffin and Sanford method)

Ascorbate cyanide screening

G6PD fluorescent screening Paroxysmal nocturnal hemoglobinuria (PNH) Sucrose hemolysis test

*Poikilocytes *Polycythemia *Anisocytes Plasma factor: most important determinant *Albumin *Lecithin Technical factor: *Overanticoagulation = EDTA = shrinkage of RBC = Hct, ESR 10 mins = 1. Initial rouleaux 40 mins = 2. Rapid settling of RBCs 10 mins = 3. Final sedimentation of RBCs 60 mins = Total Requires smaller amount of blood Involves no dilution Length: 11.5cm (115mm) Internal bore: 3.0mm Anticoagulant: Double oxalate Most sensitive Requires more blood Length: 300mm Internal bore: 2.65 ± 0.15mm Anticoagulant: Citrate (black) Anticoagulant-to-Blood ratio = 1:4 Anticoagulant: 2mL EDTA + 0.5mL NSS/Citrate Not affected by anemia Major disadvantage: requires special capillary tubes and Zetafuge ZSR = (%Hct ÷ %Zetacrit) x 100 Anticoagulant: Heparin % NaCl = # drops NaCl x 0.02 Add RBCs, stand for 2hrs at room temp Check for hemolysis (pink/red supernatant) NV: - Initial hemolysis = tube 21 or 22 (0.42-0.44%) - Complete hemolysis = tube 16 or 17 (0.32-0.34%) Detects deficiencies in the pentose phosphate pathway: - G6PD - glutathione peroxidase - glutathione reductase Rgts: - Na ascorbate - Na cyanide Normal = red (-) Enzyme = brown G6P + NADP ---(RBC: G6PD)---> 6-phosphogluconate + NADPH (fluorescence) Normal: Max fluorescence at 10mins G6PD def: Little or no fluorescence Acquired disorder in w/c red cells are abnormally sensitive to complement (-) DAF Screening test for PNH Page | 218

Ham’s acidified serum test

Patient has received normal RBCs PCH

Patient RBCs + ABO compatible serum + sucrose solution Normal = (-) Hemolysis PNH = (+) Hemolysis Confirmatory test for PNH Tube 1: Patient RBCs + normal serum + weak acid (0.2N HCl) Tube 2: Patient RBCs + patient serum + weak acid (0.2N HCl) Tube 3: Patient RBCs + normal inactivated serum + weak acid (0.2N HCl) Normal = (-) Hemolysis on all tubes PNH = (+) Hemolysis except on Tube 3 (inactivated serum) Patient w/ PNH + blood transfusion ---(Ham’s test)--->  Hemolysis

IgG autoanti-P = biphasic hemolysin - Cold = attaches to RBCs - Warm = RBC lysis Donath-Landsteiner test Test for PCH Ctrl: Patient WB  incubate at 37’C for 30mins  incubate at 37’C for 30mins Test: Patient WB  incubate at 4’C for 30mins  incubate at 37’C for 30mins Normal = (-) hemolysis on test and control PCH = (-) hemolysis on control but (+) hemolysis on test sample Autohemolysis test Blood alone ---(48 hrs)---> Hemolysis: >0.2 to 2% Blood + glucose ---> Hemolysis: 0-0.8% Blood + ADP ---> Hemolysis: 0-0.9% -----------------------------------------------------------------------------------------------------G6PD deficiency (PPP) = corrects w/ glucose only PK deficiency (EMP) = corrects w/ ADP only H. Spherocytosis = corrects w/ ADP and glucose Potential Causes of Erroneous Results with Automated Cell Counters Parameter Causes of Spurious Increase Causes of Spurious Decrease WBC count Cryoglobulin Clotting Cryofibrinogen Smudge cells Heparin Uremia plus immunosuppressants Monoclonal proteins Nucleated RBCs Platelet clumping Unlysed RBCs Platelet count Cryoglobulin Clotting Cryofibrinogen Giant platelets Hemolysis Heparin Microcytic RBCs Platelet clumping RBC inclusions Platelet satellitism WBC fragments RBC count Cryoglobulin Autoagglutination Cryofibrinogen Clotting Giant platelets Hemolysis WBC >50,000/μL Microcytic RBCs Hemoglobin HbCO >10% Clotting Cryoglobulin Sulfhemoglobin Cryofibrinogen Hemolysis Page | 219

Hematocrit (automated)

Hematocrit (microhct)

Heparin WBC >50,000/μL Hyperbilirubinemia Lipemia Monoclonal proteins Cryoglobulin Cryofibrinogen Giant platelets WBC >50,000/μL Hyperglycemia >600mg/dL Hyponatremia Plasma trapping

Autoagglutination Clotting Hemolysis Microcytic RBCs Excess EDTA Hemolysis Hypernatremia Cryoglobulin Cryofibrinogen Giant platelets Hemolysis Microcytic RBCs Swollen RBCs WBC >50,000/μL Spuriously low Hgb Spuriously high Hct

MCV

Autoagglutination WBC >50,000/μL Hyperglycemia Reduced red cell deformability

MCHC

Autoagglutination Clotting Hemolysis Spuriously high Hgb Spuriously low Hct Increased: WBC count, RBC count, Platelet count, Hgb, Hct Decreased: MCV Increased: WBC count, Hgb Decreased: Platelet count

Cryoglobulin Cryofibrinogen Heparin Clotting Hemolysis Autoagglutination Defibrinated blood

Optical light scattering

Electrical impedance

Increased: MCHC Decreased: WBC count, RBC count, Platelet count, Hgb, Hct Increased: Hgb, MCHC, Platelet count Decreased: RBC count, Hct, MCV Increased: MCV, MCHC Decreased: RBC count, Hct Blood  Glass  Beads/clips Tests: “OAA” - OFT - Autohemolysis test - Acidified serum test Automated Cell Counter Blood cells when subject to light will create forward & side light scatters w/c are detected by photodetector Forward LS = cell size Side LS/900/right angle scatter = cell granularity Ex. Technicon autoanalyzer Blood cells are nonconductors of electricity. they create impedance or resistance of current when passed in a solution that conduct electricity Ex. Sysmex counter, Coulter counter Page | 220

Coulter counter

Histograms

Ohm’s law

Positive error

Negative error Polychromasia grading

Normocytic, Normochromic RBCs

Hemolytic anemias

Triplicate count (3x) a. Blood is diluted 1:6250 (isotonic) ♫ RBCs = 36-360fL ♫ Plts = 2-20fL b. Blood is diluted 1:251 (hypotonic) ♫ Lymphocytes = 35-90fL ♫ Monocytes = 90-160fL ♫ Granulocytes = 160-450fL RBCs, WBCs, plts X-axis - Horizontal/abscissa - Size of cells Y-axis - Vertical/ordinate - Number of cells V=IxR Where: V = voltage I = current R = resistance  Count: “BEA” ♫ Bubbles ♫ Extraneous electrical pulses ♫ Aperture plug  Count ♫ Improper setting of aperture error % of RBCs that are polychromatophilic Slight = 1% 1+ = 3% 2+ = 5% 3+ = 10% 4+ = >11% 1. Defective formation of RBCs or the presence of tumor cells in BM: *Aplastic anemia *Leukemia *Hodgkin’s disease *Multiple myeloma *Leukoerythroblastosis *Metastatic cancer *Anemia of renal & endocrine disease *Anemia of inflammatory disease 2. Abnormal hemoglobin, increased destruction of RBCs *Certain acquired hemolytic anemia *PNH *Sickle cell anemia *HDN *Anemia of chronic renal insufficiency 1. Intrinsic defects w/in RBC a. Hereditary – membrane defects Page | 221

**Spherocytosis **Elliptocytosis **Acanthocytosis **Stomatocytosis **Rh null disease b. Hereditary – enzyme defects **G6PD **PK c. Hereditary – hemoglobinopathies **Sickle cell disease **Hemoglobin C disease d. Unstable hemoglobin disease **Hemoglobin E disease e. Hereditary – defective globin synthesis **Thalassemia f. Acquired **PNH 2. Extracorpuscular causes: nonimmune acquired hemolytic anemias *Chemicals, toxins, venoms *Physical trauma: disorders causing fragmentation (burns, cardiac replacement valves, MAHA, HUS) 3. Extracorpuscular causes: immune hemolytic anemias *Isoimmune antibodies: incompatible blood transfusion, HDN *Autoimmune antibodies: warm/cold reacting, drug-induced 4. Miscellaneous *Anemia of liver disease *Sulfhemoglobinemia *Porphyrias *Methemoglobinemias

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