Non-Malignant, Reactive Disorders of Lymphocytes

Self-limited lymphoproliferative disorders

o Reactive lymphocytes normal response to antigen stimulation
Greater than 20% in proportions of blood significant

Lymphocytosis absolute increase

o Greater than 4.0 x 109/L adult
o Greater than 9.0 x 109/L - infant
o Greater than 7.9 x 109/L older children

Terminology
Variant lymphocytes term of choice, proposed by CCLS
Virocytes
Reactive lymphocytes
Atypical lymphocytes
Stress lymphocytes
Downey Cells
Transformed lymphocytes
Transitional lymphocytes
Glandular lymphocytes

Causes of Lymphocytes With and Without Variant morphology

Absolute lymphocytosis with variant lymphocytes

o Infectious mononucleosis
o Acute viral hepatitis
o Cytomegalovirus infections
Relative lymphocytosis with variant lymphocytes
o Toxoplasmosis
o Viral-related disorders
Measles
Mumps
Chickenpox
Rubella
Viral pneumonia
Causes of Lymphocytes with and without variant morphology
Immune disorders
o Drug reactions
o Serum Sickness
o Idiopathic thrombocytopenia
o Autoimmune hemolytic anemia

Non-viral infections
o Tuberculosis
o Syphilis
o Malaria
o Typhus
o Brucellosis
o Rickettsia
o Diphtheria
Absolute lymphocytosis with normal lymphocytes
o Acute infectious lymphocytosis
o Bordetella persussis infection
Relative lymphocytosis with normal lymphocytes
o Neutropenia

Recognition of its benign nature

Downey and McKinlay provided the classic description of the reactive lymphocytes

Morphology of Variant or Reactive Lymphocytes

A. TYPE 1
Plasmacytoid lymphocyte
Turks irritation cells
Differentiated cells that are functionally immunocompetent and probably of cell
origin

9-20 um
Oval or round shaped
Nucleus: heavy strands, or dense (large) blocks of chromatin irregularly clumped
with sharp, small, defined areas of Parachromatin; nuclear shape may be indented or
oval
Nuclear membrane is distinct
Causes of Lymphocytes with and without variant morphology
Cytoplasm: basophilia, usually moderately basophilic
o May be vacuolated, with darker areas at the periphery
o FOAMY APPEARANCE
o Azurophilic granules

B. TYPE II
Infectious mononucleosis

Predominant type in IM

15 25 uM
Irregular or scalloped shape
Chromatin strands are coarse but not as condensed as those of type I
Rounded masses of chromatin are interspersed throughout. Nuclear shape round
or oval and is rarely lobulated.
Nuclear banding is seen in EDTA specimens
Nucleoli are not visible
Ballerina skirt appearance
Causes of Lymphocytes with and without variant morphology
Cytoplasm:
o Abundant
o N:C ratio is 1:2 to 1:4
o Few vacuoles and usually is pale, except for the basophilia at the periphery of
the cytoplasm and radiating from the nucleus
o Cell often has been described as resembling a fried egg or a flared skirt

C. TYPE III
Transformed lymphocytes or reticular lymphocytes are cells in an intermediate stage
of transformation through which the resting small lymphocyte undergoes blast
transformation and ultimately becomes a fully immunocompetent T lymphocyte or
plasma cell
12 to 35 uM
Round or irregular shaped
Nucleus: finely reticulated nuclear chromatin (finely dispersed with loose, indistinct
clumping and poorly defined Parachromatin)
Cytoplasm: Vacuolated with abundant basophilia and a clear Perinuclear area
Vacuolated Swiss cheese or moth-eaten appearance

Chromatin structure of paramount importance in distinguishing these cells from

monocytes
Delay testing and anticoagulant (EDTA) variant lymphocytes are vulnerable to the
effects of these

Lymphocyte Transformation

Blastogenesis - small lymphocytes to blast-like cell

Can be produced in vitro
o Phytohemagglutinin (PHA) T Cell

o
o
o
o

4 hours - nuclear changes

8 hours RNA production
Pokeweed mitogen (PWM) both T cell and B cell
72 hours most cells are transformed
Streptolysin S Staphylococcus endotoxin (SLS)
Anti-lymphocyte globulin (ALG)

Differentiation between Reactive and Malignant Lymphocytes

Polymorphism or the heterogeneity of variant lymphocytes major morphologic

difference
o Reactive Cells
Both large and small cells
Basophilic cells and pale cells
Immature chromatin and densely clumped chromatin are observed
o Malignant cells
Clonal
Appear very similar to one another

Absolute Lymphocytosis with Variant Lymphocyte Morphology

A. Infectious Mononucleosis

Viral disease
Young adults and teenagers
Not often seen before 10 years of age or after 40 years
Self-limited and benign
Variant lymphocytes in the peripheral blood
Heterophil antibody-positive serologic test

History
1885
o
1889
o

1920
o

1923
o
1932

Fitalov
Idiopathic lymphadenopathy in children
Pfeiffer
Non-tender cervical glandular enlargement, absence of tonsillitis, abdominal
pain and enlargement of spleen and liver
Sprunt and Evans
Chose the term infectious mononucleosis
Mononuclear leukocytosis following reaction to acute infections
Downey and McKinlay
Described the morphology of the reactive lymphocytes
Paul and Bunell

o Serological characterization
o Refined by Davidsohn and co-workers in 1955
Differential absorption test serologic test for the diagnosis of IM
o Epstein Barr virus Epstein, Anchong, and Barr
o 1964
o Found in IM patients
o Infective agent

Pathophysiology
Asymptomatic infection - childhood, particularly whose socioeconomic environment
is poor and that by age 10 years
o 60 to 90 % have been exposed to virus
40 years - most of the population have been exposed to and have acquired antibody
to EBV antigen
Anti-EBV provide lifelong immunity for most persons

EBV selectively binds to specific receptors on B lymphocytes (CD21)

Clinical features
11 days incubation period
o Onset:
Low-grade fever, then elevates as high as 106oF
Presenting symptoms
o Fever
o Pharyngitis
o Cervical lymphadenopathy
o Splenomegaly 50% of the patients
o Hepatomegaly 10% of the patients
o Rash 20% of the case

4-5 days - Prodromal stage

The disease lasts for 1-3 weeks

Complications rare
o Pneumonitis
o Meningoencephalitis
o Pericarditis
o Myocarditis
o Hepatitis

o Laryngeal edema

Laboratory features
Hematologic findings
o Absolute lymphocytosis (>5 x 109/L)
20% of variant lymphocytes
Transient leukopenia then increase between 10 to 20 x 109/L
50x109/L - leukocytes in children
Normal lymphocytes
Variant lymphocytes
Increased number of monocytes
Increased eosinophils
Proportion of the various cell types changes as the disease
progresses
All three types of variant lymphocytes present (Type II predominates)
o Appear 4 to 5 days after the onset of the disease, persists up to 30 days
o 40% or more strongly suggestive of IM

B. Cytomegalovirus Infection

Definition and clinical features

o Caused by CMV that closely resembles IM
o Do not have tonsillitis or enlarged lymph nodes
o Generally do not complain of a sore throat one of the most distinguishing
feature
Fever
Splenomegaly
Hepatomegaly 50% (10% on IM)
Rash may be present
Onset
o Fever
o Malaise
o Chills

Symptoms may persist for a longer period (3 weeks) than IM

o 35 to 40 days incubation period in adults
o 20 to 25 days - incubation period in children
Common in adults

Absolute Lymphocytosis with Normal Lymphocyte Morphology

A. Acute Infectious Lymphocytosis
1 to 10 years old, up to 14 days
Contagious, benign, self-limited
Causative agent may be viral or non-viral
Enterovirus-coxsackie A subgroup - isolated in stool specimens of 21% of patients
o Responsible for extreme lymphocytosis
12 to 20 days incubation period
Disease lasts from 3 to 5 weeks, up to 2 months

Clinical features
Asymptomatic
o Fever
o Upper respiratory infection
o Diarrhea
o Abdominal pain
Laboratory findings
Extreme Leukocytosis
May exceed 100 x 109/L

B. Bordetella pertussis Infection

70% to 90% of the leukocytes on the peripheral blood film are normal-looking
lymphocytes
o 15 to 50 x 109/L

Lymphocyte Leukemoid Reaction

Any conditions in which the lymphocytic Leukocytosis is so marked that it gives the
impression of possible leukemia qualifies as a lymphocytic Leukemoid reaction
o 50 x 109/L
May lead to an impression of acute lymphocytic leukemia

Relative Lymphocytosis with Variant Lymphocyte Morphology

a. Toxoplasmosis
Similar in clinical presentation to IM
o Fever

o Enlarged lymph nodes

Relative but not absolute increase in reactive lymphocytes
Heterophil antibody test NEGATIVE
o 10% of seronegative IM cases may be toxoplasmosis
Cells of the IM type (Type II) are not often seen
Confirmation tests
o Indirect fluorescent antibody
o Indirect hemagglutination techniques

Miscellaneous Disorders
o Measles
o Mumps
o Chickenpox
o Hepatitis
o Resoela
Lymphopenia followed within a few days by a relative lymphocytosis

Pleomorphic blood picture (variant lymphocytes predominate)

Upon recovery, blood picture normalizes, small lymphocytes increase and some of the
large lymphocytes become plasmacytoid

Immune responses, recent immunizations, hypersensitivity reactions, and

autoimmune diseases all produce the same type of lymphoid reactions
Absolute number of lymphocytes does not increase
Increase in mitotic forms
Increased DNA synthesis
Type III immature lymphocytes may be seen may cause confusion with malignant
lymphoproliferative disorders
10% of patients with thyrotoxicosis have neutropenia and relative
lymphocytosis
Relative Lymphocytosis with normal lymphocyte morphology

Neutropenia
Up to 4 years old lymphocytes are predominant