Table of contents :

• granulocytes
• Auer rods are a hallmark of acute myeloid leukemia (AML) but occasionally are seen in myelodysplastic syndromes (MDS) or chronic myelomonocytic leukemia, rarely in cases with < 5% blasts, where signify aggressive biology^ref. Auer rod-like inclusions with a smooth surface in the neighborhood of a well-developed rough endoplasmic reticulum, but with no direct relation to it, a fine lamellar substructure, and the periodicity of the filamentous striations was about 10 nm, were reported in a case of IgA multiple myeloma^ref and in adult common type acute lymphoblastic leukemia^ref


• eosinophils
• left shift : eosinophil metamyelocyte in peripheral blood. Found in:
• reactive eosinophilia
• myeloproliferative disorders
• AML

• monocytes
• monocyte vacuolization : vacuoles in the cytoplasm of monocyte. Found in infections


• neutrophils
• Pelger-Huët anomaly (PHA) is an autosomal dominant disorder characterized by abnormal nuclear shape and chromatin organization in blood granulocytes, caused by heterozygous mutation in the sterol D¹⁴-reductase activity of the lamin B receptor (LBR), whose homozygosity causes the lethal autosomal recessive fetal chondrodystrophy hydrops-ectopic calcification-'moth-eaten' (HEM), or Greenberg, skeletal dysplasia. Heterozygotes show hypolobulated neutrophil nuclei with coarse chromatin. Presumed homozygous individuals have ovoid neutrophil nuclei, as well as varying degrees of developmental delay, epilepsy, and skeletal abnormalities. The nucleus of the granulocytes is hyposegmented (ALI = 1.12-1.60), being rodlike, dumbbell- or peanut-shaped, or spectaclelike. This anomaly is also found in the rabbit.
• pseudo-Pelger-Huët (PH) anomaly : bilobed neutrophils with more condensed chromatin.


Aetiology :
• primary haematological disorders
• inherited
• myelodysplastic syndromes (MDS)
• idiopathic myelofibrosis
• chronic myeloid leukaemia (CML)
• chronic lymphocytic leukemia (CLL)
• infections
• infectious mononucleosis (HHV-4 / EBV)
• Plasmodium spp.
• myxoedema
• drugs
• mycophenolate mofetil (MMF) + ganciclovir in the setting of heart and/or lung transplantation.
• colchicine
• ibuprofen
• approximately 15 primary (presumably congenital) defects of neutrophil function associated with recurrent infections had been described, and at least 30 additional conditions had been reported in which decreased neutrophil function had been reasonably well documented to be a consequence of another, primary disease
• Undritz anomaly / hypersegmentation of nuclei of PMN
• macro neutrophils : twice the size of a normal neutrophil with tetraploid DNA content. Found in:
• occasionally in the blood of healthy subjects
• inherited
• administration of G-CSF
• megaloblastic anaemia
• chronic infections

• specific granule deficiency : mutations in CEBPE (a myeloid-specific transcription factor) cause lack of lactoferrin in specific granules => frequent bacterial infections
• Chediak-Higashi syndrome (CHS) : mutations in lysosomal trafficking regulator gene (LYST) cause
• deficiency of cathepsin G (a constituent of the azurophil granule; defensins, which are also constituents, are normal or only mildly decreased in the CHS patients) and leukocyte elastase (microbicidal/cytotoxic action)
• defective surface expression of CTLA4 by T lymphocytes => lymphoproliferative disease
• delayed peptide loading onto MHC class II molecules and antigen presentation
Symptoms & signs : frequent bacterial infections, albinism, blonde hairs, pale skin, photophobia
Laboratory examinations : giant granulations in all blood cells, disorders in granule formation in other cell types (hepatocytes, adrenal cortical cells, pituitary cells)
• leukocyte alkaline phosphatase (LAP)
• deficiency
• chronic myeloid leukaemia (CML)
• paroxismal nocturnal hemoglobinuria
• increase :
• reactive neutrophilia to bacterial infections (but not viral)
• after administration of G-CSF
• Down syndome
• pregnancy
• myeloperoxidase (MPO)
• MPO deficiency : neutrophils appear normal on Romanowsky stain but are not counted as neutrophils by the cell counters employing a myeloperoxidase stain
• inherited
• acquired
• myelodysplastic syndromes
• diabetes mellitus
• lead intoxication
• cytostatics
• blast crisis of chronic myeloid leukaemia (CML)
• Amato-Döhle basophilic inclusion bodies : single or multiple light blue or gray staining round to oval areas in the periphery of the cytoplasm of a neutrophil. They are RER containing RNA and may represent localized failure of the cytoplasm to mature. Similar structures, usually larger and more prominent, are present in granulocytes other than neutrophils in the Hegglin-May anomaly (HMA)

Aetiology :
• bacterial infections (scarlet fever, ...) and inflammatory states
• severe burns
• Mycobacterium tuberculosis
• post chemotherapy
• poisoning
• uncomplicated aplastic anemia
• pregnancy

• Alder-Reilly anomaly
• Reilly granulations : large azurophilic granules in the cytoplasm of polymorphonuclear leukocytes and lymphocytes, occurring in Hurler's syndrome.
• leukocyte adhesion deficiency (LAD) :
• LAD1 : leukocyte adhesion deficiency type-1 (LAD-1) is a well-known autosomal recessive disorder caused by genetic defects in CD18, the common chain of the ß₂ integrin family (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). LAD-1 neutrophils have profound adhesive and motility defects. Patients present with recurrent severe infections, including deep tissue abscesses caused by S aureus or gram-negative enteric organisms, and also have neutrophilia but impaired formation of pus
• LAD2 results from mutations in the Golgi GDP-fucose membrane transporter (GFTP) / SCL35C1^ref (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010) which results in a generalized loss of expression of fucosylated glycans on the cell surface of cells. Thus, LAD neutrophils are unable to bind to E- and P-selectin receptors on endothelium. Infections are less severe than LAD-1, but patients also have developmental delay as well as manifesting the Bombay (hh) erythrocyte phenotype due to lack of fucosylation of RBC membrane proteins
• single amino acid exchanges in the GFTP impair its function but not its subcellular localization to the Golgi
• dual defect in function and Golgi expression of the GFTP due to the absence of 2 important molecular regions. Furthermore, the missing part of the GFTP can be dissected into 2 regions, one that is needed for Golgi localization and one that is additionally required for the function of the GFTP^ref
• LAD3 has been described in 4 patients and appears to be an autosomal recessive disorder characterized by functional defects in the activation of multiple classes of integrins in response to G protein-coupled chemokine receptor stimulation, possibly due to impaired activation of the Rap1 GTPase^ref. These patients had severe recurrent infections and leukocytosis, similar to LAD-1, and a bleeding tendency.
• Job syndrome
• Kartagener syndrome
• lazy leukocyte syndrome : a syndrome of unknown etiology, usually seen in children, marked by recurrent low-grade infections, associated with a defect in neutrophil chemotaxis and deficient random mobility of neutrophils
• macropolycyte : a large PMN leukocyte with 6 to 14 lobes in the nucleus, seen in conditions such as pancytopenia, vitamin B₁₂ or folic acid deficiency, and intoxications involving neutrophilic leukocytosis
• polycyte : an abnormal PMN leukocyte of normal size but with more than the usual number of lobes in the nucleus
• iodophil granules : granules staining brown with iodine, seen in PMN leukocytes in various acute infectious diseases.
• neutrophil aggregation : small clumps of neutrophils. Happens in vitro if EDTA anticoagulated blood is allowed to stand. May lead to incorrect WBC. Found in:
• in vitro finding
• infectious mononucleosis (HHV-4 / EBV)
• bacterial infections
• autoimmune disease

• hypersegmentation or right shift of neutrophil nuclei :
• average lobe count increased
• increased % of neutrophils with > 5 lobes
• > 3% neutrophils with > 5 lobes
Aetiology :
• megaloblastic anaemia
• iron deficiency
• chronic infections
• liver disease
• uremia
• hereditary

• shift to the left : presence of precursor of granulocytes in the peripheral blood. Found in:
• normal in pregnancy or neonate
• infections
• bone marrow fibrosis
• bone marrow infiltration by malignancies

• ring shaped nuclei : nucleus ring or doughnut shaped

Aetiology :
• acute myeloid leukemia (AML)
• chronic myeloid leukaemia (CML)
• megaloblastic anaemia
• myelodysplastic syndromes (MDS)

• detached nuclear fragments in cytoplasm

Aetiology :
• dysgranulopoiesis
• patients on anti cancer chemotherapy
• HIV-1

• toxic granules or granulation : increased dark-staining more basophilic and larger than normal granules observed in neutrophils; they are probably phagosomes or autophagic vacuoles and are thought to be primary granules. Artifactual heavy granulation caused by poor staining is seen evenly spread throughout each cell and in all granulocytes, whereas toxic granulation is unevenly spread throughout the cytoplasm of certain cells. Large amounts of toxic granulation can give the neutrophil a bluish appearance

Aetiology :
• severe bacterial infections
• non specific finding - seen in tissue damage of various types.
• normal pregnancy
• therapy with cytokines

• degenerative index : the percentage of neutrophils exhibiting toxic granulation (basophilic granules probably representing phagosomes or autophagic vacuoles)
• hypogranulation : reduced granulation in neutrophil cytoplasm. Found in myelodysplastic syndromes (MDS)


• phagocytosed parasites. Found in severe Plasmodium falciparum infection


• phagocytosed organisms : DF2 organism. Rod shaped organism in vacuoles in cytoplasm of neutrophils. Found in dog bite


• phagocytosed platelet : platelet in vacuole in neutrophil cytoplasm

Aetiology : infections

• phagocytosed red blood cell : RBC in vacuole in cytoplasm of neutrophil

Aetiology :
• infections
• autoimmune haemolytic anaemia (AIHA)
• incompatible blood transfusion

• necrobiotic or apoptotic neutrophil : dense homogenous nuclei (pyknotic)

Aetiology :
• occasionally in healthy subjects
• in vitro artefact
• acute myeloid leukemia (AML)

• vacuoles in the cytoplasm of granulocytes

Aetiology :
• infections
• toxic effect of ethanol
• Jordan's anomaly

• phagocytosis and killing deficits
• Alius-Grignaschi anomaly
• chronic granulomatous disease (CGD)
• CGD1
• CGD2
Epidemiology : affects one in 250,000 people worldwide
Aetiology : defects in the phagocyte nicotinamide dinucleotide phosphate (NADPH) oxidase (also referred to as the respiratory burst oxidase) (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). Superoxide generated during the phagocyte respiratory burst is the precursor to numerous microbicidal oxidants, including hydrogen peroxide and myeloperoxidase-catalyzed formation of hypochlorous acid. Respiratory burst-derived oxidants are an important component of the innate immune response, and their absence results in recurrent, often life-threatening bacterial and fungal infections and is also associated with formation of inflammatory granulomas, a distinctive feature of CGD. The NADPH oxidase is a phagosomal and plasma membrane-associated enzyme complex that is dormant in resting neutrophils and rapidly assembled when cells are activated by a variety of inflammatory stimuli^ref. 4 polypeptide subunits are essential for NADPH oxidase activity and mutations in the corresponding genes are responsible for the four different genetic subgroups of CGD. The oxidase subunits are referred to by their apparent molecular mass (kDa) and have been given the designation phox, for phagocyte oxidase. Overall, CGD has a minimum estimated incidence of between 1/200,000 and 1/250,000 live births^ref.

Shown is the assembled form of the enzymatically active NADPH oxidase, along with subunits affected in the four different genetic subgroups of CGD, the approximate incidence, and the chromosomal location of the corresponding gene. Flavocytochrome b558 is the redox center of the enzyme, and is located in plasma, specific granule, and phagolysosomal membranes. This heterodimer is comprised of the gp91^phox and p22^phox subunits of the NADPH oxidase, which are affected in X-linked and an autosomal recessive form of CGD, respectively. The soluble regulatory proteins p47^phox, p67^phox, and p40^phox are found in the cytosol until phagocyte activation by soluble or particulate inflammatory stimuli, upon which they move to the membrane where p47^phox and p67^phox bind flavocytochrome b558. Mutations in the genes encoding p47^phox and p67^phox account for two autosomal recessive forms of CGD. Another essential regulatory component of the NADPH oxidase is the small GTPase, Rac, which in its active GTP-bound state, becomes membrane-bound and associates with the oxidase. By a mechanism that is not fully understood, binding of these multiple regulatory subunits activates the flavocytochrome to catalyze the transfer of electrons from cytosolic NADPH across the membrane via the FAD and heme redox centers to molecular oxygen, thereby forming superoxide in the extracellular or intraphagosomal compartment. The Rap1a GTPase co-purifies with flavocytochrome b558, but its function in superoxide production is unknown. No cases of CGD have been described due to mutations in p40^phox, Rac, or Rap1a.
Approximately 66% of CGD cases result from defects in the X-linked gene encoding the gp91^phox subunit of flavocytochrome b558, a membrane-bound heterodimer that is the redox center of the oxidase. The X-linked form of CGD is sometimes denoted as the X91 subgroup. The flavocytochrome is present in the plasma membrane, and, in neutrophils, much resides in the specific granules, which fuse with either the phagolysosome or plasma membrane upon cellular activation. The gp91^phox subunit contains both flavoprotein and heme-binding domains responsible for electron transport. A rare autosomal recessive form of CGD (A22 CGD) is caused by mutations in the gene encoding p22^phox, the smaller subunit of flavocytochrome b558, which contains a docking site for p47^phox. The remaining cases of autosomal recessive CGD (A47 and A67 CGD) involve genetic defects in either p47^phox or p67^phox, 2 regulatory proteins that are associated with each other in the cytosol of unstimulated cells. When neutrophils or macrophages are exposed to inflammatory or phagocytic stimuli, p47^phox and p67^phox rapidly move to the membrane to activate flavocytochrome b558 and induce superoxide formation. Mutations identified in the genes encoding gp91^phox, p22^phox, and 67^phox are very heterogenous. In contrast, virtually all A47 patients are either homozygotes or compound heterozygotes for a mutant allele with a GT deletion at the beginning of exon 2 that predicts a premature stop codon. The high frequency of the p47^phox GT deletion mutation appears to reflect the existence of highly conserved and closely linked p47^phox pseudogenes, which leads to recombination events with the wild-type gene (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010)
Other regulatory subunits of the NADPH oxidase : regulation of superoxide formation also involves the small GTP-binding protein Rac and possibly Rap1a, which act as molecular switches through conformational changes between the GDP and GTP-bound forms. Rac-GTP binds to the membrane and to p67^phox, and is required for NADPH oxidase activity. A fifth phox protein, p40^phox, is also bound to p67^phox and may additionally help to regulate NADPH oxidase activity. Genetic defects in Rap1a, Rac, or p40^phox have not been reported in CGD. However, a dominant-negative mutation in the hematopoietic-specific Rac2 GTPase was identified in an infant with a clinical picture more similar to leukocyte adhesion deficiency. Neutrophils showed normal leukocyte ß₂ integrin expression but severe defects in adhesion and motility, along with partial NADPH oxidase defects^{ref1, ref2}.
Pathogenesis : the generation of respiratory burst oxidants is essential for normal killing within the phagosome, acting in concert with proteases, defensins, and other compounds released into the phagosome by fusion of different granule populations. Activation of the NADPH oxidase also results in changes in intraphagosomal pH that facilitate microbial killing^ref. The importance of granule compounds for intact innate immunity is well illustrated by the rare neutrophil function defect, specific granule deficiency. In this disorder, which is due in at least some cases to mutations in the myeloid transcription factor C/EBP, patients lack primary granule defensins, gelatinase, and all secondary granule proteins, and consequently suffer from a variety of bacterial infections.1 Of note, studies in knock-out mice genetically deficient in neutrophil elastase show enhanced susceptibility to gram-negative organisms such as Klebsiella and Escherichia coli, and mice deficient in cathepsin G and/or elastase appear to be more susceptible to Aspergillus^ref. The optimal release of granule matrix-associated proteases and other proteins into the phagosome lumen may depend on ion fluxes set into motion by changes in membrane potential resulting from NADPH oxidase-mediated electron transport across the membrane^ref. However, it is considered unlikely that the main function of the NADPH oxidase is to promote granule protein activation. A large body of evidence supports the view that respiratory burst oxidants have direct microbicidal effects^{ref1, ref2}. The specific ions transported in response to the electrogenic effects of the NADPH oxidase also remain a topic of active investigation^{ref1, ref2, ref3}.
Expansion of CD5⁺ B cells, and profound reduction in B cells expressing the memory B cell marker, CD27, both independent of the age, genotype, and clinical status of the patients, and not accompanied by altered CD5 and CD27 expression on T cells. Focusing on CD27⁺ B cells, considered to be memory cells based on somatically mutated Ig genes, the reduction was not caused by CD27 shedding or abnormal retention of CD27 protein inside the cell. Rather, it was determined that CD27^- B cells were, appropriately, CD27 mRNA negative, consistent with a naive phenotype, whereas CD27⁺ B cells contained abundant CD27 mRNA and displayed SHMs, consistent with a memory B cell phenotype. Thus, it appears that CGD is associated with a significant reduction in the peripheral blood memory B cell compartment, but that the basic processes of somatic mutation and expression of CD27 are intact. X-linked carriers of CGD revealed a significant correlation between the percentage of CD27⁺ B cells and the percentage of neutrophils with normal NADPH activity, reflective of the degree of X chromosome lyonization. These results suggest a role for NADPH in the process of memory B cell formation, inviting further exploration of secondary Ab responses in CGD patients^ref.
Symptoms & signs : the clinical manifestations of CGD typically begin in infancy or early childhood. CGD patients are particularly susceptible to Staphylococcus aureus, Aspergillus spp., Nocardia spp., and a variety of gram-negative enteric bacilli including Serratia marcescens, Salmonella spp. and Burkholderia cepacia. Granulobacter bethesdensis has been recently isolated from lymph nodes. Many of these organisms contain catalase, which prevents CGD phagocytes from utilizing microbe-generated hydrogen peroxide to promote killing of ingested organisms. Frequent sites of infection include skin and its draining lymph nodes, lungs, bone and gastrointestinal tract, including Staphylococcal liver abscesses, which are almost unique to CGD^ref (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). In contrast to infections with bacteria and Nocardia, Aspergillus species infections can often be indolent with absence of fever or leukocytosis, and few if any symptoms^ref. Although S. aureus is the most frequently isolated organism overall, the most common causes of death reported in a recent series were pneumonia and/or sepsis due to Aspergillus or B. cepacia^ref
Many CGD patients also develop chronic inflammatory granulomas, which are a distinctive hallmark of this disorder. Symptomatic disease can include colitis/enteritis or granulomatous obstruction of either the gastric outlet or urinary tract. A recent analysis of 140 patients with CGD followed at the National Institutes of Health revealed inflammatory involvement of the gastrointestinal tract in 32.8% of patients, 89% of whom had X-linked inheritance^ref. In some cases, granuloma formation is a response to active infection, but in many cases it is believed to reflect a dysregulated inflammatory response and/or inefficient degradation of inflammatory mediators and debris in the absence of respiratory burst-derived oxidants^{ref1, ref2}. Production of oxidants appears to be an important trigger of neutrophil apoptosis at sites of inflammation, which is also important for resolution of the inflammatory response. Recent studies have shown that apoptosis is delayed in CGD neutrophils^{ref1, ref2, ref3}.
Correlation between genetic defect and clinical course : as a group, patients with X-linked CGD, A22 CGD, and A67 CGD tend to have a more severe clinical course compared to patients with A47 CGD^ref (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). This may reflect residual superoxide formation by p47^phox-deficient neutrophils, which can be detected using sensitive fluorescent probes. Some X91 patients have a partially functional gp91^phox, associated in some cases with a milder clinical course(Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). However, despite the fact that > 90% of patients with non-p47^phox-deficient forms of CGD have undetectable levels of O₂^– production, there is a surprising clinical heterogeneity^ref (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). At one end of the spectrum are patients who develop severe and recurrent bacterial and fungal infections beginning during infancy. At the other end of the spectrum are patients who are well for many years and then unexpectedly develop a serious infection typical of CGD. Polymorphisms in oxygen-independent antimicrobial systems or other components regulating the innate immune response are likely to play an important role in modifying disease severity. These remain to be fully defined, although specific polymorphisms in the myeloperoxidase, mannose binding lectin, and FcgRIIa genes are associated with a higher risk for granulomatous or autoimmune/rheumatologic complications in CGD^ref.
Therapy :
• prophylactic antibiotics and interferon-g (IFN-g), coupled with aggressive treatment of acute infections and prolonged courses of antimicrobial treatment, has markedly improved the clinical course of patients with CGD. Trimethoprim/sulfamethoxazole (or, in sulfa-allergic patients, dicloxacillin) is ordinarily used for antibiotic prophylaxis. Prophylactic IFN-g is another mainstay of current management, although its use is not accompanied by any measurable improvement in phagocyte NADPH oxidase activity in the majority of CGD patients. The clinical benefit of IFN-g is probably related to enhanced phagocyte function and killing by non-oxidative mechanisms and perhaps the NOS2 and xanthine oxidase pathways. A large, multicenter trial initially established that recipients of IFN-g had 70% fewer and less severe infections^ref. A recent update reinforced these findings, reporting only 0.30 serious bacterial infections and 0.12 serious fungal infections observed per patient-year, in patients observed for up to 9 years, with a total observation period of 328.4 patient-years^ref. The most common side effects were fever and flu-like symptoms. Importantly, there was no increase in the incidence of chronic inflammatory complications of CGD in patients receiving IFN-g. A new study showed that itraconazole is an effective agent for prophylaxis for fungal infections in CGD, as evaluated in a randomized, double blind, placebo-controlled study conducted by the National Institutes of Health^ref. Hence, for all patients with CGD, regardless of genetic subgroup, the current recommendation is to use prophylaxis with trimethoprim/sulfamethoxazole, itraconazole, and IFN-g. Corticosteroids are used to treat clinically significant granulomatous complications of CGD, although with caution, given the underlying microbial killing defect. The prognosis of CGD has improved dramatically in the past 2 decades with the advent of prophylactic antimicrobials and IFN-g (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). The overall mortality rate in the study on long-term IFN-g therapy cited above was 1.5% per patient-year^ref, and may be even lower in newly diagnosed children managed with optimal care, including the use of anti-fungal prophylaxis. It will be important to continue to monitor the changing outlook for patients with this disease, in order to weigh the risks and benefits of approaches using stem cell transplantation.
• allogeneic HSCT can be used to treat CGD and has been employed successfully (Dinauer M. The phagocyte system and disorders of granulopoiesis and granulocyte function. In: Nathan D, Orkin S, Ginsburg D, Look A, eds. Nathan and Oski’s Hematology of Infancy and Childhood. Vol. 1 (ed 6th). Philadelphia: W.B. Saunders Company; 2003:923–1010). However, because of the risks associated with this procedure and the frequent lack of an HLA-matched sibling, conventional marrow transplantation has generally been considered only for those patients who have frequent and severe infections despite aggressive medical management. Some success has also been achieved in transplants done in the setting of active infection^ref. The development of reduced intensity conditioning regimens for allogeneic transplantation may be an emerging approach for stem cell transplantation in CGD. A "mini-transplant" regimen was used successfully in a small number of children, but GvHD was a significant problem in the adult patients in this study^ref.
• gene therapy targeted at hematopoietic stem cells (HSCs)^ref. Observations on female carriers of X-linked CGD, variant X-linked CGD patients with residual enzyme activity, and preclinical studies in murine CGD models suggest that complete correction of respiratory burst activity in ~10% of circulating neutrophils would lead to clinically relevant improvements in host defense, particularly against Aspergillus^ref. However, correction of > 20% of neutrophils will likely provide broadest protection against bacterial infection and granulomatous complications^{ref1, ref2}. The relative level of superoxide within individual neutrophils may also be an important factor, and only partial correction of cellular NADPH oxidase activity may not restore full antimicrobial activity^ref. The majority of preclinical studies in CGD to date have used gamma-retroviral vectors, although lentiviral vectors have attracted increasing attention. Lentiviral vectors can transduce quiescent cells, which is an advantage for future use in human hematopoietic stem cells. "Self-inactivating" lentiviral vectors with deleted viral enhancer sequences may also provide safety advantages over gamma-retroviral vectors, because the former tend to insert into the body of the gene rather than near gene promoters, with less chance of activating expression of neighboring genes^ref. Several phase I CGD gene therapy clinical trials using cytokine-mobilized peripheral blood CD34⁺ cells have either been completed or are ongoing. In initial trials by Malech and colleagues at the NIH^ref and by a group at the Indiana University School of Medicine, retrovirally transduced autologous peripheral blood CD34⁺ cells were reinfused into patients without any bone marrow conditioning. MPO⁺ peripheral blood neutrophils were observed over the following months, although numbers were very low (at most, 0.2% of neutrophils) and disappeared altogether within 1 year. These studies suggested that, not surprisingly, marrow conditioning prior to reinfusion of transduced cells was going to be important in order to achieve higher-level engraftment of corrected stem/progenitor cells. A new trial being conducted in Europe for X-linked CGD patients utilizes moderate dose busulfan as conditioning prior to infusion of CD34⁺ cells transduced with a gamma-retroviral vector for gp91^phox expression (Grez M, Ott M, Stein S, et al. Correction of chronic granulomatous disease by gene therapy. Mol Ther. 2005;11:S130–131). In the 2 patients reported thus far, both adults, higher than expected numbers of oxidase-positive granulocytes were seen post-transplant, which then increased in the months following reinfusion, reaching over 35% in one patient and ~15% in the second. Both patients are currently well, with normal peripheral blood counts, and chronic infections associated with CGD have resolved. Analysis of peripheral blood granulocyte DNA showed that the majority of proviral insertions were non-random, and the authors postulated that vector-mediated activation of genes at the insertion sites contributed to the increase in oxidase-positive neutrophils (Schmidt M, Schwarzwaelder K, Ott M, et al. Stable polyclonal hematopoietic repopulation after successful clinical gene therapy of chronic granulomatous disease (CGD). Mol Ther. 2005;11:S415). A recent study using the mouse transplant model also suggested that retroviral integration might trigger non-malignant expansion in murine hematopoiesis due to transcriptional activation of neighboring genes^ref. The long-term significance of these findings is currently unknown.
• combinatory approaches : 2 adults received gene therapy after nonmyeloablative bone marrow conditioning for the treatment of X-linked CGD showed substantial gene transfer in both individuals' neutrophils that lead to a large number of functionally corrected phagocytes and notable clinical improvement. Large-scale retroviral integration site–distribution analysis showed activating insertions in MDS1-EVI1, PRDM16 or SETBP1 that had influenced regulation of long-term hematopoiesis by expanding gene-corrected myelopoiesis 3- to 4-fold in both individuals. Although insertional influences have probably reinforced the therapeutic efficacy in this trial, gene therapy in combination with bone marrow conditioning can be successfully used to treat inherited diseases affecting the myeloid compartment such as CGD^ref.
NADPH oxidases: beyond phagocytic leukocytes : numerous studies have now reported detecting the expression of gp91^phox, p22^phox, p67^phox, and p47^phox in vascular endothelial cells and/or smooth muscle cells^ref. Expression of these components as well as oxidant production appears to be much lower than in phagocytic leukocytes. The physiologic significance of phox expression in non-phagocytic cells remains to be resolved, but it has been speculated that derivative reactive oxidants may play a role in intracellular signaling. Other potential sources of reactive oxidants, e.g., from xanthine oxidase, mitochondria, or other NAD(P)H oxidases, has made it difficult to ascribe any specific functions to vascular phox protein expression. However, studies in CGD knockout mice have provided some support that endothelial cell expression of the phagocyte NADPH oxidase plays a role in inflammation. For example, gp91^phox-deficient mice transplanted with ß-S sickle cell marrow had decreased leukocyte and platelet adhesion in the cerebral microvasculature^ref. Mammalian homologs of the gp91^phox flavocytochrome have also been recently discovered^{ref1, ref2}. This family is known as the NOX (NAD(P)H oxidase) proteins, of which there are 5 members, including gp91^phox, which is designated as NOX2 in this classification. All NOX proteins share a similar protein structure, with multiple trans-membrane domains for heme binding and an intracellular flavoprotein domain. The other NOX proteins are expressed in various cell types, including the epithelium, smooth-muscle cells, gut and the endothelium, and appear capable of generating superoxide, generally at much lower levels than the phagocyte enzyme, and other reactive oxygen species, including hydrogen peroxide. The regulation of oxidant production by these enzymes and their biologic roles are currently under intense investigation. At least some of the other NOX flavocytochromes appear to be regulated by homologs of p67^phox and p47^phox. The derivative oxidants are proposed to mediate signal transduction and, in the gut, may function in innate immunity. The phagocyte NADPH oxidase can thus be viewed as a specialized, high output system for producing superoxide, and it will be fascinating to compare this well-studied enzyme and its associated pathophysiology with emerging findings on the other NOX members.
Experimental animal models : gene targeting has been used to develop mouse models for both X-linked (gp91^phox-/-) and an autosomal recessive (p47^phox-/-) form of CGD^{ref1, ref2}. CGD mice have abnormalities in both host defense and inflammation that are similar to their human counterpart, confirming the importance of the respiratory burst in innate immunity. CGD mice exhibit a marked increase in susceptibility to the opportunistic pathogens, B cepacia and Aspergillus species^{ref1, ref2, ref3, ref4}, 2 organisms that are particularly problematic in CGD patients. Other organisms showing increased virulence in CGD patients and, similarly, in CGD mice include S aureus^ref, Salmonella typhimurium, Mycobacterium tuberculosis, and Candida^{ref1, ref2}. The generation of reactive nitrogen intermediates via inducible nitric oxide synthase (NOS2) is a second oxygen-dependent phagocyte antimicrobial system that plays an important role in host defense^ref. Mice with a double deficiency in both the NADPH oxidase (gp91^phox-/-) and NOS2 have a high rate of spontaneous infection with commensal organisms, mostly enteric bacteria, whereas mice with a single enzyme deficiency rarely exhibit spontaneous infections when raised in specific pathogen-free conditions^ref. Superoxide production from xanthine oxidase, which is expressed in endothelial cells and other tissues, may be another source of antioxidants that can function as a back-up to the phagocyte NADPH oxidase^ref. Both gp91^phox- and p47^phox-deficient CGD mice also have abnormalities in the inflammatory response. These include a marked increase in exudate neutrophils compared to wild-type mice in response to peritoneal instillation of thioglycollate^{ref1, ref2}, which may be related to impaired degradation of leukotriene B₄^ref.14 gp91^phox-/- mice exhibit an exaggerated acute inflammatory response after instillation of sterilized hyphae into the lungs or upon intradermal injection, which evolves into a chronic granulomatous infiltrate^{ref1, ref2}. In models of experimental arthritis, both gp91^phox- and p47^phox-deficient CGD mice had more severe joint inflammation that developed into a granulomatous synovitis^ref. These studies support the concept that respiratory burst products play an important role in inflammation outside of their function in microbial killing. Whether absence of phagocyte NADPH oxidase activity has a protective effect in diseases with an inflammatory component has also been investigated using knockout CGD mice. Decreased injury has been reported in some models including stroke due to transient occlusion of the carotid artery, whereas protection against atherosclerotic lesions has generally not been observed^ref.
• a neutrophil defect resulting from a dominant-negative mutation in the Rac2 GTPase has also been described in one patient and is associated with poor neutrophil adhesion and motility, along with impaired NADPH oxidase activation and degranulation in response to chemo-attractants^{ref1, ref2}. The presentation was similar to LAD, with neutrophilia, absent pus at sites of infection, and deep-seated soft tissue abscesses. The molecular basis of the dominant-negative Rac2 mutation is incompletely understood but presumably results from interference in Rac-regulated signaling pathways downstream of integrin and chemoattractant receptors. Of interest, this phenotype is similar to that reported for Rac2 knockout mice^{ref1, ref2}.
• a recently described group of inherited phagocyte functional disorders are due to genetic defects in macrophage IL-12 production or the IFN-g receptor axis, which present with recurrent and severe atypical mycobacterial infections, including multifocal osteomyelitis^ref. Ingestion of mycobacteria normally leads to macrophage production of IL-12, which in turn stimulates T cells and natural killer cells to produce IFN-g, which then activates macrophages via downstream signals carried by JAK kinases and the STAT1 transcription factor^{ref1, ref2}. A variety of autosomal recessive as well as autosomal dominant mutations have been described in the IFN-g receptor complex, the IL-12R, and STAT1 that lead to susceptibility to nontuberculous mycobacterial infection and BCG. These disorders have been grouped as Mendelian susceptibility to mycobacterial disease (MSMD), and > 100 patients have been described overall^ref. Patients with more severe forms of this disorder, with complete IFN-g receptor defects, are also susceptible to Salmonella and certain viral infections. Management of patients depends on the specific molecular defect. Patients with autosomal dominant defects in the IFN-g receptor (which commonly involves a truncated form of the IFN-g receptor) or IL-12–related defects can be treated with subcutaneous IFN-g, whereas this is ineffective in complete IFN-g receptor defects. Long-term prophylaxis against mycobacterial infections with azithromycin or clarithromycin is recommended.
• lymphocytes : see diseases of immune system
• atypical lymphocytosis : pleomorphic. Large with diameter of 15 - 30 µm. Abundant, strongly basophilic cytoplasm. Basophilia may be confined to the cytoplasmic margins
• Türk's cell or irritation leukocyte : a nongranular, mononuclear cell displaying morphologic characteristics of both an atypical lymphocyte and a plasma cell, observed in the peripheral blood during severe anemias, chronic infections, and leukemoid reactions

Aetiology :
• viruses
• HHV-4 / EBV
• HHV-5 / CMV (neither pharyngotonsillitis nor cervical lymphadenopathy)
• HHV-6
• HIV-1
• HIV-2
• mumps virus
• rubella virus
• HAV (higher transaminases)
• measles virus
• bacterial infections
• Brucella spp.
• Mycobacterium tuberculosis
• Bordetella pertussis
• Ehrlichia sennetsu
• protozoa
• Plasmodium spp.
• acute infection by Toxoplasma gondii (no pharyngotonsillitis, lower fever, Sabin-Feldman reaction)
• drug reactions
• immunization
• SLE
• plasmacytoid lymphocyte : lymphocyte with basophilic cytoplasm and eccentric nucleus. Found in reactive phenomenona


• mature lymphocytes with a small cleft or indentation in the condensed chromatin of the nucleus, a finding often found in cases of chronic lymphocytic leukemia (CLL)


• Mott cell / mulberry, berry, grape, or morular cell : an abnormal plasma cell that contains Mott bodies (globular inclusions composed of immunoglobulin) or Russell bodies, seen in reactive changes in peripheral blood, expecially
• trypanosomiasis
• multiple myeloma

• hairy cells


• smudge, basket (BC) or shadow cell / Klein-Gumprecht shadow nuclei (F. Gumprecht:Leukozytenzerfall im Blute bei Leukämie und bei schweren Anämien.Deutsches Archiv für klinische Medizin, Leipzig, 1896, 57: 523-548) : reddish-purple nuclear remnant of a ruptured immature leukocyte of any type that has undergone partial breakdown during preparation of a stained smear or tissue section, because of its greater fragility; smudge cell's are seen in largest numbers in acute leukoses^ref and expecially in chronic lymphocytic leukemia (CLL)


• Russell or fuchsin bodies : globular plasma cell inclusions in the lumen of ER cisternae, mucoprotein in nature, containing surface gamma globulin, and representing aggregates of misfolded immunoglobulins synthesized by the cell; they are seen in both chronic inflammatory and malignant disorders (multiple myeloma). At the end of the immune response most undergo TRAIL-dependent apoptosis.


• thesaurocyte : an abnormal plasma cell that is distended with homogeneous cytoplasm that stains gray or red, possibly owing to a disturbance in synthesis of IgA; it may be related to a flaming plasma cell
• flaming plasma cell : an abnormal plasma cell that stains red to violet, probably because it contains immunoglobulins with a high carbohydrate content; it may be related to a thesaurocyte
• Dutcher-Fahey body (DB) : a PAS⁺ intranuclear invagination of immunoglobulin-containing cytoplasm found in neoplastic plasmacytoid lymphocytes (with any cIg-producing B-cell lymphoma^ref, but expecially lymphoplasmacytoid lymphoma/immunocytoma, MALT lymphoma) and plasma cell in both benign (chronic synovitis^ref) and malignant (Waldenstrom macroglobulinemia, and myeloma) conditions.

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