Williams Hematology




Light Microscopy and Peroxidase Histochemistry

Electron Microscopy and Peroxidase Cytochemistry

Other Cytoplasmic Changes During Maturation

Contents of Neutrophil Granules

Pathologic Alterations of Granules

Light Microscopy of Eosinophils in Marrow and Blood Films

Electron Microscopy and Cytochemistry

Basophils and Mast Cells
Chapter References

Early in precursor development in the marrow, cells destined to be leukocytes of the granulocytic series, neutrophils, eosinophils, and basophils, synthesize proteins and store them as cytoplasmic granules. The synthesis of primary or azurophilic granules defines the conversion of the myeloblast, a virtually agranular, primitive cell that is the earliest granulocyte precursor identifiable by light microscopy into the promyelocyte, which is rich in azurophilic granules. Synthesis and accumulation of secondary or specific granules follows. The appearance of specific granules marks the progression of the promyelocyte to neutrophilic, eosinophilic, or basophilic myelocytes. Thereafter, the cell continues maturation into an amitotic cell with a segmented nucleus, capable of ameboid motility, phagocytosis and microbial killing. The mature granulocytes also develop cytoplasmic and surface structures that permit them to attach to and penetrate the wall of venules. The mature granulocytes enter the blood from the marrow, circulate briefly, and move to the tissues to carry out their major function of host defense. The neutrophil is highly phagocytic and can kill a variety of microorganisms. The eosinophil and basophil are specialized to participate in allergic inflammatory responses. The stages of maturation from promyelocyte to mature cell can be recognized on a stained film of marrow using a light microscope. Further details of granulocyte structure and inherited and acquired abnormalities of neutrophil granules are portrayed and reviewed in this chapter.

Acronyms and abbreviations that appear in this chapter include: AGEs, advanced glycation end products; AML, acute myelogenous leukemia; CML, chronic myelogenous leukemia; ECF-A, eosinophil chemotactic factor of anaphylaxis; HLA, human leukocyte antigens; LAMPs, lysozomal-associated membrane proteins; LAP, leukocyte alkaline phosphatase; MLC, multilaminar compartment; MVB, multivesicular bodies; PAS, periodic acid-Schiff; SRS-A, slow-reacting substance of anaphylaxis; VEGF/VPF, vascular endothelial growth factor/vascular permeability factor

In the normal adult human, the life of neutrophils is spent in three environments: marrow, blood, and tissues. Marrow is the site of differentiation of stem cells into neutrophil progenitors and of proliferation and terminal maturation of neutrophilic granulocytes (myeloblast to segmented neutrophils)1,2,3 and 4 (Fig. 64-1). Precursor cell proliferation, consisting of approximately five divisions, takes place only during the first three stages of neutrophil maturation (blast, promyelocyte, and myelocyte). After the myelocyte stage, the cells are no longer capable of mitosis and enter a large marrow storage pool. After five days, they are released into the blood, where they circulate for a few hours before entering tissues.5,6

FIGURE 64-1 Diagrammatic representation of neutrophil [polymorphonuclear neutrophil (PMN)] life-span and stages of maturation. For discussion, see text. Out of every 100 nucleated cells in marrow, 0.5 percent are myeloblasts, 5 percent are promyelocytes, 12 percent are myelocytes, 22 percent are metamyelocytes and bands, and 20 percent are maturing and mature neutrophilic cells, yielding a total of ~60 percent developing neutrophils in normal human marrow. The azurophilic (primary) granules, which are peroxidase-positive, are shown as solid black dots; the other granules are shown as open dots and are discussed in more detail in the text. Basically, the peroxidase-negative granules may be divided into specific/secondary granules and gelatinase/tertiary granules based on their relative content of lactoferrin and gelatinase. (Modified from Bainton et al.2)

Figure 64-1 is a diagrammatic representation of the stages of neutrophil maturation.1,2 The myeloblast is an immature cell with a large, oval nucleus, sizable nucleoli, and few or no granules. The cell, derived from progenitor cells, matures into the promyelocyte. In the promyelocyte stage, large peroxidase-positive granules that stain metachromatically (reddish-purple) with a polychromatic stain such as Wright’s stain, the azurophilic or primary granules, are formed. During the next, or myelocyte, stage of maturation the specific or secondary granules, which are peroxidase-negative, are formed. The metamyelocyte and band neutrophils are nonproliferating cells that precede the development of the mature neutrophil. The mature, segmented neutrophilic cells contain primary, peroxidase-positive granules and specific peroxidase-negative granules in a one to two ratio. The nucleus of the circulating neutrophil is segmented, usually into two to four interconnected lobes.
During the myelocyte stage, the larger, metachromatic, azurophilic granules lose their intense staining properties and are no longer evident by light microscopy of stained blood films. This diminution of the metachromatic staining results from an increase in acid mucin-containing molecules that form complexes with basic proteins of the azurophilic granules.7 However, the presence of large (about 500 nm), peroxidase-positive, azurophilic granules in mature neutrophils is evident by electron microscopy.2 Thus, the violet-colored granules seen with light microscopy in mature neutrophils on Wright’s-stained blood films are azurophilic granules whose staining characteristics have altered during maturation. Therefore, with light microscopy, the most reliable method for identifying azurophilic granules on blood films is to stain the cells for peroxidase. Most of the peroxidase-negative granules are in a size range (about 200 nm; see below) at the limit of resolution of the light microscope; they cannot be distinguished individually, but are responsible for the pink background color of neutrophil cytoplasm during and after the myelocyte stage.
The purpose of the nuclear segmentation is not known. Fluorescence in situ hybridization with chromosome-specific probes has shown that chromosomes are randomly distributed among the nuclear lobes.8 Some mature neutrophils in women have drumstick- or club-shaped nuclear appendages. These appendages contain the inactivated X chromosome. An X chromosome-specific nucleic-acid probe has confirmed the position of the X chromosomes in the drumstick structure of leukocyte nuclei by in situ hybridization.9
The peroxidase reaction has become a key tool with which to study the formation of the azurophilic granule. The dense product of the peroxidase reaction serves as a marker of azurophilic granules in human marrow and blood cells for electron as well as light microscopy.2
The earliest precursor in the evolution of the neutrophil from the colony-forming unit is an immature cell with a large nucleus and multiple nucleoli. The nucleolus is the site of assembly of ribosomal proteins and rRNA and is a prominent feature of early maturing cells. The scant cytoplasm contains reaction product for peroxidase within the rough-surfaced endoplasmic reticulum and Golgi cisternae and, sometimes, in early developing azurophilic granules.
As shown in Fig. 64-2, the promyelocyte produces and accumulates a large population of peroxidase-positive granules. Most of these granules are spherical and have a diameter of 500 nm, but there are also ellipsoid, crystalline forms, as well as small granules connected by filaments.10 As with other secretory cells, peroxidase is present throughout the secretory apparatus of the promyelocyte, for example, in cisternae of the rough endoplasmic reticulum, in all Golgi cisternae, in some vesicles, and in all developing granules.2

FIGURE 64-2 Electron micrograph of a neutrophilic promyelocyte reacted for peroxidase from normal human marrow. This cell is the largest of the neutrophilic series. It has a sizable, slightly indented nucleus with a nucleolus (nu), a prominent Golgi region (G), and cytoplasm packed with dense peroxidase-positive (p+) azurophilic granules of varying shapes and sizes. Peroxidase reaction product is visible in less concentrated form within all compartments of the secretory apparatus—endoplasmic reticulum (er), perinuclear cisterna, and Golgi cisternae (G). No reaction product is apparent in the cytoplasmic matrix or mitochondria (m). X8000

At the end of the promyelocyte stage, peroxidase abruptly disappears from rough endoplasmic reticulum and Golgi cisternae and the production of azurophilic granules ceases. The myelocyte stage begins with the production of the peroxidase-negative specific granules.
As shown in Fig. 64-3, the only peroxidase-positive elements at this stage are the azurophilic granules. The specific granules are formed by the Golgi complex (Fig. 64-4). They vary in size and shape but are typically spherical (about 200 nm) or rod-shaped (130 × 1000 nm). About three cell divisions occur at this stage of maturation. Mitoses can be observed (Fig. 64-5) and the two types of granules appear to be distributed to the daughter cells in fairly equal numbers.

FIGURE 64-3 Neutrophilic myelocyte reacted for peroxidase. At this stage, the cell is smaller than the promyelocyte, the nucleus is more indented, and the cytoplasm contains two different types of granules: (a) large, peroxidase-positive azurophilic granules (p+) and (b) the generally smaller specific granules (p–), which do not stain for peroxidase. A number of immature specific granules (is)—larger, less compact, and more irregular in contour than mature granules—appear in the Golgi region (G). Note that peroxidase reaction product is present only in azurophilic granules and not in the rough surfaced endoplasmic reticulum (er), perinuclear cisterna (pn), or Golgi cisternae (G). This is in keeping with the fact that azurophilic granule production has ceased and only peroxidase-negative specific granules are produced during the myelocyte stage. (ce, centriole.) X20,000

FIGURE 64-4 Golgi region of a neutrophilic myelocyte reacted for peroxidase. As in the preceding figure, peroxidase reaction product is found in azurophilic granules (p+), but not in specific granules (p–). The stacked, smooth-surfaced Golgi cisternae (G) are oriented around the centriole (ce). X43,000

FIGURE 64-5 Myelocyte in the late stage of mitosis, from rabbit marrow. This myelocyte is in telephase. Note that the granules are being relatively equally distributed to the daughter cells. X15,000

The late stages of maturation consist of non-dividing cells that can be distinguished by their nuclear morphology, mixed granule populations, small Golgi regions, and accumulations of glycogen particles. On the average, an electron micrograph of a neutrophil will display 200 to 300 granules and about one-third will be peroxidase-positive (Fig. 64-6).

FIGURE 64-6 Mature neutrophil from normal human marrow, reacted for peroxidase. The cytoplasm is filled with granules of the two basic types: the smaller, pale, peroxidase-negative granules (p–) and the large, dense, peroxidase-positive granules (p+). The nucleus is condensed and lobulated (n1–n4), the Golgi region (G) is small and without any forming granules, the endoplasmic reticulum is scant, and mitochondria (m) are few. X21,000

The peroxidase-negative granules are more numerous than peroxidase-positive granules during the myelocyte stage because peroxidase granule formation ceases after the promyelocyte stage, the number of peroxidase-positive granules per cell is reduced by mitoses, and peroxidase-negative granules continue to be produced by each myelocyte generation.1
Microperoxisomes are present from the promyelocyte stage through the development of mature neutrophils.11 These organelles are small membrane-bound vesicles that contain catalase. Although this enzyme is known to destroy H2O2, it can also act as a peroxidase; its exact function in neutrophils has yet to be determined.
Changes in cell surface carbohydrates, glycoproteins, glycolipids, and HLA antigens occur during maturation (reviewed in Ref. 12). For example, the densities of membrane HLA-A, B, and C antigens decrease with granulocyte maturation. Some surface antigens appear during neutrophil maturation. The development of chemotactic and recognition capabilities parallels the acquisition of certain membrane receptors.13,14 Fc receptors are not present, or are poorly expressed, on progenitors younger than myelocytes, whereas over 90 percent of mature neutrophils have Fc receptors. Mature neutrophils possess at least two classes of receptors for fragments of the complement component C3, called CRI and CR3. Other maturational changes occur in cytoskeletal elements, such as microtubules,15 and in biophysical features such as deformability and surface charge.12,16 During early myeloid development, direct interactions must occur between hematopoietic cells and the components of the marrow microenvironment, both cellular and extracellular matrix.17,18,19,20,21,22,23,24 and 25 Most of the known matrix protein receptors belong to the b1 integrin family. On CD34+ marrow cells, a4b1 and a5b1 are expressed. During myeloid differentiation a5b1 is lost at the myelocytic-metamyelocyte stage, before the loss of a4b1 at the band stage.21 ICAM-1, a member of the immunoglobulin superfamily, is detected on blasts and promyelocytes, but is lost at later stages of myeloid maturation.21 One of the members of the new adhesion molecule family of selectins, L-selectin, can be detected as early as the colony-forming unit for granulocytes and monocytes,24 through the mature neutrophil stage, until it is shed within minutes after activation.25
During granulocytic maturation, numerous genes that encode proteins important for the specific functions of mature cells are expressed.26,27 Myeloperoxidase and elastase mRNA transcripts are found almost exclusively at the promyelocyte stage, but myeloperoxidase mRNA disappears earlier than elastase mRNA.28 Lactoferrin mRNA transcripts are detected later in neutrophil maturation, marking the beginning of the myelocyte stage28 (see Fig. 64-7). Mature neutrophils are capable of synthesizing and secreting interleukin-1 as well as tumor necrosis factor a.29 In addition, bacterial infection induces nitric oxide synthase in human neutrophils.30

FIGURE 64-7 Granules defined by timing of biosynthesis of their characteristic proteins. The granules formed at any given stage of maturation of neutrophil precursors will be composed of the granule proteins synthesized at that time. MB, myeloblast; PMC, promyelocyte; MC, myelocyte; MMC, metamyelocyte; BC, band cell; Segm., segmented cell. (Reproduced with permission from Borregaard and Cowland.28)

Programmed cell death, or apoptosis, is a physiologic phenomenon associated with the elimination of mature cells. Apoptosis is characterized biochemically by internucleosomal DNA fragmentation, and morphologically by nuclear and cytoplasmic condensation, and it plays an important role in cell removal.31,32 There is evidence that senescent neutrophils and eosinophils undergo apoptosis. One of the key features of programmed cell death in many tissues is the phagocytosis of apoptotic cells by macrophages. Ingestion of intact apoptotic granulocytes by macrophages may prevent the release of their toxic intracellular contents extracellularly, thereby promoting resolution of inflammation.
Initially, the granules were classified into two major types, based on their content of peroxidase. It is now recognized that granules can be further subdivided on the basis of other granular and membrane proteins (see Fig. 64-8).

FIGURE 64-8 Classification of granules in neutrophils. Peroxidase-positive (azurophilic or primary) granules are characterized by their content of myeloperoxidase and may be further divided based on their content of defensins into large, defensin-rich granules and the smaller defensin-poor granules. The peroxidase-negative granules may be divided into specific (secondary) granules and gelatinase (tertiary) granules on the basis of their relative content of lactoferrin and gelatinase. All granules contain lysozyme. Secretory vesicles share some of their membrane proteins with peroxidase-negative granules, whereas others are unique to secretory vesicles. Def., defensins; Gela., gelatinase; Tert., tertiary. (Reproduced with permission from Borregaard and Cowland.28)

The components of human neutrophilic granules have been analyzed by both cytochemical and fractionation procedures2,28,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,
86,87,88,89,90,91,92,93,94,95,96,97 and 98 and are extensively covered in Chap. 68.
In addition to myeloperoxidase, the azurophilic granule contains numerous lysosomal enzymes. Elastase,64,65 and 66 proteinase 3,66,67 and a-1 antitrypsin78 co-localize with some peroxidase-positive granules. Bactericidal factors such as defensins,46,56,59,71,98 azurophil-derived bactericidal factors,42 and bactericidal permeability-increasing protein,48 which were previously called cationic proteins, have been found in some azurophilic granules.52 Lysozyme has been found in both azurophilic and specific granules.68,69 and 70
Of the ten antimicrobial proteins of known sequence in the human azurophil granules,55 two have unique primary structures (lysozyme and bactericidal permeability-increasing protein), while the remaining eight fall into two families of four members each: the defensins (which compromise 30 to 50 percent of granule proteins) on the one hand, and cathepsin G, elastase, proteinase-3, and azurocidin on the other. These latter four proteins can be termed “serprocidins,” to denote that they are closely related to serine proteases with microbicidal activity.55 Very little is known about the limiting membrane of azurophilic granules, but CD6380,92 and CD6879 are present. We had anticipated that the lysosomal-associated membrane proteins (LAMPs) would be found there, but such was not the case.77,93 Rather, LAMPs were absent in all identified granule populations, but were consistently found in the membranes of vesicles, multivesicular bodies (MVB), as well as in multilaminar compartments (MLC), which are identified by their content of concentric arrays of internal membranes.93
The specific or secondary granule, which, by definition, does not contain peroxidase, contains lactoferrin, lysozyme, B12 binding proteins, and other proteins.28,89 These peroxidase-negative granules vary greatly in size, shape, electron-lucency, isopycnic density and granule content. However, they can be loosely categorized by the distribution of two proteins, lactoferrin and gelatinase. Approximately 16 percent of the peroxidase-negative granules contain only lactoferrin, 24 percent only gelatinase, and 60 percent contain both marker enzymes. Thus, based on ultrastructure alone, three types of peroxidase-negative granules can be identified: peroxidase-negative granules, containing gelatinase but no lactoferrin, peroxidase-negative granules, containing lactoferrin but no gelatinase, and peroxidase-negative granules, containing both lactoferrin and gelatinase.88 This heterogeneity may be a result of overlapping synthesis and packaging of different granule proteins during granulopoiesis and is functionally significant as the gelatinase-containing granules are released from the cells by certain inflammatory mediators more readily than those containing lactoferrin.28
These vesicles are distinct from the azurophilic or specific granules and have been defined as intracellular organelles that contain CD35 and latent alkaline phosphatase.28,83,88,89 The latter enzyme is located on the luminal side of the vesicle membrane and can therefore be identified, in the presence of detergent, as latent alkaline phosphatase. This localization was also demonstrated by enzyme cytochemistry.73 Further, these secretory vesicles contain plasma proteins, such as albumin, that are not synthesized by the cells, but are endocytosed from plasma. These represent a specialized form of endocytic vesicle. Secretory vesicles are transported to the cell surface after the stimulus of formyl methionyl-leucyl phenylalanine or certain cytokines.89
Other proteins found in neutrophil granules are discussed in Chap. 67, reviews28,89 and other papers.32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,
71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97 and 98 Two membrane adhesion proteins have been found on the tips of neutrophil microvilli in resting neutrophils, L-selectin, and P-selectin glycoprotein-1.94,95 and 96
Leukemic cells can be shown to contain chemical properties unique for a given normal cell line, and thus are considered to be of that particular cell lineage. This has been particularly helpful in subdividing the acute leukemias. For example, peroxidase is recognized as one of the earliest synthetic products of granulocytic precursor cells. Production of this enzyme by leukemic cells has been the hallmark for distinguishing acute lymphocytic from myelogenous leukemia.99 Chloroacetate esterases appear early in maturation, and are used to detect the origin of the immature cells in granulocyte sarcomas. The substrate used for this incubation, naphthyl AS-D chloroacetate, is a general substrate of neutrophil proteinases. Lactoferrin is recognized as a marker of specific granules.
Pathologic neutrophil granulations can be classified as a selective abnormality of a granule type.100,101 Pathologic granules in hereditary or acquired disease states can be classified as either abnormalities of azurophilic granules or specific granules (Table 64-1).


Quantitative Neutrophils sometime contain either smaller- or larger-than-normal numbers of azurophilic granules, or the azurophilic granule population may be missing. Some mature neutrophils lack azurophilic granules in acute myelogenous leukemia (AML)102,103 or in the blast crisis of chronic myelogenous leukemia (CML).104 Children with severe congenital neutropenia and repeated life-threatening infections have neutrophilic abnormalities that include: (1) defective synthesis or degeneration of azurophilic (primary) granules, (2) an absence or marked deficiency of specific (secondary) granules, and (3) autophagia. This rare disease has been called congenital dysgranulopoietic neutropenia.105
Absence of Granule Contents In some instances, azurophilic granules can form that lack one or more enzymes or other substances. For example, in hereditary myeloperoxidase deficiency, the azurophilic granules of neutrophils and monocytes,106,107 but not eosinophils or basophils, lack peroxidase (Fig. 64-9). This deficiency occurs in one in 2000 to 5000 persons108,109 and is not usually associated with clinical abnormalities. Although not detectable with enzyme assays, peroxidase can be revealed by immunologic methods in the neutrophils of persons with the deficiency.110 Molecular analysis of cells from family members with this deficiency has revealed mutations of the gene(s) that resides on chromosome 17 and encodes a protein that is incapable of post-translational processing and thus is enzymatically inactive.111,112 Peroxidase deficiency has also been observed in refractory anemia,113 in preleukemia,114,115 and in the blast crisis of CML.104 In all these examples of peroxidase deficiency, both types of granules are present and apparently normal; only the enzyme is missing. In the hereditary deficiency, all the neutrophils are peroxidase-negative, whereas in the refractory anemias and leukemias,116,117 the percentage of peroxidase-negative neutrophils varies. Neutrophils lacking peroxidase are observed in AML and in the case of blast cell transformation of CML.104 This abnormality, when present, affects 8 to 70 percent of the circulating neutrophils. The deficient neutrophils may originate from the leukemic precursors. A high neutrophil peroxidase activity is present in the neutrophils of patients with megaloblastic anemia.118 Finally, immunologic techniques for peroxidase were found to be useful in the diagnosis of minimally differentiated acute myeloid leukemia (AML-M0).119

FIGURE 64-9 Neutrophil reacted for peroxidase, from the blood of a patient with hereditary peroxidase deficiency. Note that both types of granules are present, the large azurophilic granules (ag), pale because of the absence of peroxidase, and the small specific granules (sg). (m, mitochondria; n, nucleus.) X19,000

Abnormal Variants Auer bodies, found in the immature cells of some patients with AML, are abnormally large, elongated, azurophilic granules, containing peroxidase, lysosomal enzymes, and large crystalline inclusions.99,103,120,121 and 122 Although similar to normal azurophilic granules in content and staining properties, Auer bodies are “abnormal” because they are so large (Fig. 64-10). Furthermore, Auer body formation in leukemic blasts and promyelocytes differs markedly from the normal secretory process of azurophilic granule formation in that Golgi cisternae contain very little peroxidase.103,119 More Auer bodies can be detected on marrow and blood films from patients with AML when special stains, e.g., peroxidase, chloroacetate esterase, acid phosphatase, or Sudan black, are applied than when the Romanovsky stain is used. Not all Auer bodies exhibit all of these staining characteristics at the same time. Auer rod formation may be an occasional but normal phenomenon in fetal hematopoiesis.123 Auer rod-like inclusions can also be seen at the light microscopic level in certain B-cell neoplasms, but they are peroxidase-negative.124

FIGURE 64-10 Peroxidase localization in an abnormal immature cell from a patient with acute myelogenous leukemia. Note the Auer body (Au) with its crystalline inclusion and a matrix containing peroxidase. (G, Golgi cisternae; ve, vesicles, rer, RER.) X40,000

The Chédiak-Higashi anomaly or syndrome, a rare autosomal recessive disease, is characterized clinically by oculocutaneous albinism and increased susceptibility to infection, and microscopically by the presence of abnormally large lysosome-like organelles in most granule-containing cells (see Chap. 72). The large inclusions in the neutrophils of persons with Chédiak-Higashi syndrome are enormous abnormal azurophilic granules.125,126 Early in neutrophil maturation, normal azurophilic granules form, but they then fuse together to form megagranules. Later, during the myelocyte stage, normal specific granules form. The mature neutrophils contain both the abnormal azurophilic and the normal specific granules (Fig. 64-11). The contents of specific granules can be present in the megagranules,127 presumably because of limited fusion with megagranules. There is an absence of elastase and cathepsin G, along with defensin content, in patients with Chédiak-Higashi syndrome.128 The syndrome results from a mutation of the gene, LYST, which encodes a protein with multiple phosphorylation sites.129

FIGURE 64-11 Peroxidase localization in a neutrophil from a patient with Chédiak-Higashi syndrome. Note that the large megagranules are peroxidase-positive (arrows), whereas the specific granules appear normal (sg). X26,000

Giant peroxidase-positive granules have been observed in the neutrophils of a patient with neutrophil dysfunction.130,131 These granules were structurally similar to those seen in Chédiak-Higashi syndrome, but the neutrophils were biochemically different in that there was defective activation of the respiratory burst.
Giant round granules have been observed in Wright’s-stained cells from patients with acute myelomonocytic leukemia.132 This acquired abnormality closely mimicked the giant-round granules seen in the Chédiak-Higashi syndrome, and is termed the pseudo-Chédiak-Higashi anomaly.133,134 In marrow from patients with AML, one may observe enormous round pink inclusions that resemble ingested erythrocytes in blasts and promyelocytes. Electron microscopy and peroxidase cytochemistry show that these inclusions are homogeneous large, membrane-bound, peroxidase-positive granules that correspond to the abnormal granules seen in the pseudo-Chédiak-Higashi anomaly. Like the Auer rods also seen in AML, these granules are an abnormal variant of peroxidase-positive azurophils. Their lack of azurophilic staining is due to the absence of sulfated glycosaminoglycans.135
In certain inflammatory disorders, morphologic changes occur in blood neutrophils. The best-known alteration is the “shift to the left,” which denotes the presence of bands, metamyelocytes, and sometimes myelocytes in the blood. The mature neutrophil can also display cytoplasmic modifications, including: (1) “toxic” granules, which stain more prominently than those of normal neutrophils; (2) light-blue, amorphous inclusions called Döhle bodies; and (3) vacuoles. Toxic granules are azurophilic granules that have an abnormal staining pattern when viewed with the light microscope136 but are indistinguishable from normal azurophilic granules when viewed by electron microscopy. Döhle bodies are not granules; rather, they have been defined as several rows of rough endoplasmic reticulum. They stain as blue bodies in the cytoplasm because of the ribosomes bound to the membrane of the reticulum (Fig. 64-12). Toxic neutrophils have decreases in chemotaxis and in phagocytic and intracellular bactericidal activities.137,138 Increased numbers of lipid bodies have been observed in inflammatory reactions139 and other inclusion bodies can be seen in certain hereditary conditions.140,141 and 142

FIGURE 64-12 A portion of a neutrophil depicts a Döhle body (D): it consists of three stacks of rough endoplasmic reticulum (rer). It stains blue by light microscopy because of the concentration of ribosomes.

An acquired azurophil granule abnormality occurs in neutrophils of patients with amiodarone pulmonary toxicity.143 Some of the peroxidase-positive azurophil granules contain lamellar inclusions. The target antigen of anticytoplasmic antibodies in patients with Wegener’s granulomatosis is proteinase 3, located in azurophilic granules.66,67,144,145 and 146
Quantitative The three quantitative abnormalities of azurophilic granules described above apply to specific granules as well: circulating neutrophils can have smaller- or larger-than-normal quantities of these granules or lack them entirely.
The absence of specific granules was first observed in 1974 in a 14-year-old boy with recurrent infection whose neutrophils lacked leukocyte alkaline phosphatase (LAP).147 More cases have been reported.148,149,150,151,152,153,154 and 155 These patients have an abnormality that affects production of specific granules and their protein contents, and at least two additional proteins (gelatinase and defensins).148,149,150,151,152,153,154 and 155 There are abnormalities in the peroxidase-positive granules of these patients.152 In congenital dysgranulocytic neutropenia, specific granules may be absent or markedly decreased in number.105
This absence of certain normal organelles from mature neutrophils in patients with acute leukemia has been documented by electron microscopic and cytochemical studies. There can be an absence of specific granules in neutrophils from patients with AML.103 This absence or paucity of specific granules in the more mature segmented neutrophils in certain leukemic patients results from a cessation of cytoplasmic development after the promyelocytic stage, whereas nuclear maturation progresses in a fairly normal fashion. These abnormal neutrophils are frequent in AML with maturation (i.e., the M2 variety) and in myelodysplastic syndromes. After treatment of acute promyelocyte leukemia with all-trans retinoic acid, aberrant peroxidase-positive granules, including Auer rod, have become normal, although the neutrophils lacked the specific (secondary) peroxidase-negative population.156 Furthermore, neutrophils in patients with AML can be deficient in all granules.157
Absence of Granule Contents There are no well-documented examples in this category. The specific granules are present in normal numbers in all neutrophils of patients with CML.158 The low leukocyte alkaline phosphatase score seen in most CML is associated with undetectable levels of mRNA, so the protein is not being synthesized.159 Two major antibacterial proteins, lysozyme and lactoferrin, can specifically bind glucose-modified proteins bearing advanced glycation end products (AGEs).160 Exposure to AGE-modified proteins inhibits the enzymatic and bacterial activity of lysozyme, and blocks the bacterial agglutination and bacterial killing activities of lactoferrin.
Abnormal Variants Morphologically abnormal variants of specific granules have not been reported. Other granule abnormalities161 that cannot be subclassified include the Alder-Reilly anomaly, in which the cytoplasm of neutrophils contains prominent granules that stain a deep lilac color (see color plate in Ref. 161). The inheritance pattern of this disorder is not clear, but it may be part of a general metabolic disorder of polysaccharides. The May-Hegglin anomaly is an autosomal dominant disorder characterized by leukopenia, and the presence of abnormally large basophilic bodies in neutrophils, eosinophils, basophils, monocytes, and giant platelets. There are marked differences between these large inclusions and the Döhle bodies, which develop with infection. In the May-Hegglin anomaly the blue area is occupied by rods and small granules, which may be ribosomes.162
The Pelger-Huët anomaly, an inherited disorder, is characterized by abnormal lobe development in granulocytes; neutrophils can have a monolobed (homozygote) or bilobed (heterozygote) appearance. This abnormality can be mimicked in the neutrophils of patients with AML (acquired Pelger-Huët anomaly).161 Hypersegmentation of neutrophils is a characteristic of folate and vitamin B12 deficiencies, but it can also be seen after hydroxyurea or glucocorticoid therapy.163 In patients suffering from severe alcoholism, ring-shaped nuclei may be seen in granulocytes.164 Peculiar fibrillary inclusions of both the cytoplasm and nuclei may be seen by ultrastructural examination in the neutrophils of human renal allograft recipients who have serious infections.165 Neutrophils of patients with infection may show nuclear pyknosis, degranulation, and vacuolation166 in addition to toxic granulation and Döhle bodies. Döhle bodies may also be found in the neutrophils of pregnant women for unexplained reasons.167 Multiple persistent vacuoles can be seen in neutrophils, eosinophils, monocytes, and their precursors in familial Jordan’s anomaly.168 Döhle bodies and inclusions of May-Hegglin anomaly have also been reported in the Fechtner syndrome, which includes nephritis, deafness, congenital cataracts, and macrothrombocytopenia.140 Abnormal neutrophil granules consisting of large membranous whirls have been observed after chloroquine therapy169 and amiodarone toxicity.143
The earliest identifiable form of an eosinophilic leukocyte is as a late myeloblast or early promyelocyte. This cell is about 15 µm in diameter, has a large nucleus with nucleoli, and a few blue or azurophilic granules in intensely basophilic cytoplasm. The later eosinophilic promyelocyte and myelocyte contain mostly acidophilic granules. The fully mature eosinophilic leukocyte has a bilobed nucleus and its cytoplasm is filled with large eosinophilic granules whose rims stain for peroxidase and Sudan black. Multilobed nuclei, comparable to those of neutrophils, are rare.170 Eosinophils are susceptible to mechanical damage during the preparation of blood films. Eosinophilic precursors may degranulate during maturation.171 Lipid bodies can be found in eosinophils172 as well as in neutrophils.
Eosinophils of the promyelocyte and myelocyte stages stain positively for peroxidase in all cisternae of the rough-surfaced endoplasmic reticulum, including transitional elements and the perinuclear cisterna; clusters of smooth vesicles at the periphery of the Golgi complex, all cisternae of the Golgi complex, and all immature and mature specific granules.3,173 The mature granules are completely filled with peroxidase except in areas occupied by centrally located crystals.
In the later stages of development, after granule formation has ceased, the eosinophils contain few of the organelles associated with the synthesis and packaging of secretory proteins. The endoplasmic reticulum is sparse or virtually non-existent, and the Golgi complex is small and inconspicuous. The cytoplasm of the mature eosinophil (Fig. 64-13) primarily contains granules and glycogen. Most of the granules are specific granules with crystals, which are usually centrally located. After the myelocyte stage, peroxidase can no longer be detected in the endoplasmic reticulum or Golgi elements of the eosinophil by any of the enzyme procedures; however, it can be found in the matrix of granules.3,173

FIGURE 64-13 Human mature eosinophil incubated for peroxidase. Reaction product is present only in granules (g). The rough endoplasmic reticulum (er), including the perinuclear cisterna (pn) and the Golgi cisternae (Gc), does not contain reaction product. Most of the granules (arrow) contain the distinctive crystalline bar. X8000 (Reproduced with permission from Bainton.4)

Eosinophil granules contain abundant peroxidase and lysosomal enzymes.3 Eosinophil peroxidase is genetically and biochemically distinct from neutrophil peroxidase, and it appears to play no role in the eosinophil’s bactericidal activity.174 Eosinophils have much less bactericidal activity than do neutrophils.175 The specific granules of eosinophils are true peroxisomes in that they also contain catalase,176 two enzymes of peroxisomal lipid b-oxidation (enoyl-CoA hydratase and ketoacyl-CoA thiolase177), and a flavoprotein, (acyl-CoA oxidase178). All of these substances have been found in the matrix, but not the crystalloid, of the granule. Lectins have also been identified in eosinophil granules, most heavily in the crystalloids.179 The eosinophil granule is also known to contain several basic proteins: a major basic protein, eosinophil cationic protein, and eosinophil-derived neurotoxin.180,181,182,183,184 and 185 More than half of the granule protein is the major basic protein, which constitutes the crystalline core of the granule. It is cytotoxic to parasites as well as normal mammalian cells and induces histamine release from basophils and mast cells.184 The other two cationic proteins are found in the matrix of the granule.180,181 and 182 Eosinophil cationic protein can cause the formation of transmembrane pores and may thereby cause membrane damage.184 The amino-acid sequence of eosinophil cationic protein is homologous with that of eosinophil-derived neurotoxin, and both sequences show striking homology with that of ribonuclease.185,186 Eosinophils also contain proteoglycans,187 interleukin-6,188 tumor necrosis factor-a,189 transforming growth factor-a,190 and granulocyte-macrophage colony-stimulating factor.191
Charcot-Leyden crystals, bipyramidal crystals observed in fluids in association with eosinophilic inflammatory reactions, possess lysophospholipase activity and comprise 7 to 10 percent of total eosinophil protein.192,193,194 and 195 The ultrastructural localization of this protein is in a large, crystal-free granule and supports the presence of a distinct primary granule population (»5%) in mature eosinophils.3,194,195
Inherited Abnormalities of Eosinophils There are four inherited abnormalities of eosinophils: (1) The absence of peroxidase and phospholipids in eosinophils is an autosomal-recessive defect that produces no signs of disease;196,197 (2) In Chédiak-Higashi syndrome,125 almost all granulated cells, including eosinophils, contain large abnormal granules; (3) A family was found to have gray inclusions in eosinophils and basophils; this abnormality was autosomal dominant and had no clinical effects. Electron microscopy revealed cytoplasmic crystals and curved lamellar bodies in the cells;198 (4) Neutrophil-specific granule deficiency, previously described, also involves eosinophils.150
Several acquired gross morphologic or cytochemical abnormalities of eosinophils have been observed in leukemias or in association with benign eosinophilias (see below).
Cytochemistry of Abnormalities in Leukemias In a cytochemical study of eosinophils in acute leukemia,199 the cells were considered normal when they did not show toluidine blue metachromasia or positivity for alkaline phosphatase, chloroacetate esterase, Astra blue, or periodic acid-Schiff (PAS), but did show positivity for peroxidase and Sudan black, and moderate reactivity with naphthol-AS or alpha-naphthyl esterase. The observation of chloroacetate esterase activity in some abnormal eosinophils is of particular interest in view of the subsequent finding that abnormal marrow eosinophils in acute myelomonocytic leukemia are associated with the inversion of chromosome 16.200 Most of the patients studied had a higher than normal percentage of immature eosinophils containing a mixture of eosinophilic and basophilic granules. The eosinophilic granules showed abnormal reactivity for chloroacetate esterase and periodic acid Schiff. None of the granules had well-formed central crystalloids.
An abnormality seen in patients with CML is the presence of basophilic and eosinophilic granules in eosinophilic myelocytes and, occasionally, in mature eosinophils.201 Eosinophilic and basophilic granules are mutually exclusive markers of the respective granulocytic lineages; the presence of both markers in CML cells is a sign of lineage infidelity.
Degranulated and light density eosinophils are associated with eosinophilia.181,202,203 There is an expanding clinical spectrum of multisystem diseases associated with eosinophilia204 (see Chap. 68).
Intranuclear Crystals Associated With Abnormal Granules Eosinophils with abnormal granules and intranuclear crystalloids were observed in a 2-year-old girl with chronic benign neutropenia.205 The father had the same morphologic abnormality, but was asymptomatic and had normal leukocyte counts.
Incomplete segmentation of the nucleus of mature eosinophils is seen in AML206 and myelodysplasia.207 Eosinophil accumulation, activation, fate, and apoptosis have recently been reviewed.208,209 and 210
Basophils and mast cells are distinct cell lines, although they have many functional similarities.211,212,213,214,215,216 and 217 The granules of both cell types stain metachromatically, but they are distinct218,219 and 220 when examined by electron microscopy (Fig. 64-14 and Fig. 64-15). The cells can phagocytose sensitized red cells but are less active phagocytes than the other granulocytes and lack significant amounts of antibacterial or lysosomal enzymes. Basophils are found in small numbers in blood (0.5%) and can be seen in tissues in which inflammation resulting from hypersensitivity to proteins, contact allergy, or skin-allograft rejection is present.

FIGURE 64-14 Mature basophil from human blood, reacted for peroxidase. Note unusually large nucleus (n) and scattered glycogen particles (gl). Human basophil granules contain peroxidase, as illustrated by their density (due to the presence of reaction product) in this type of preparation. They are usually spherical, difficult to fix, and may be speckled in appearance (arrow). X17,000 (Reproduced with permission from Bainton.4)

FIGURE 64-15 Portion of a mast cell from human bone marrow. Note that the granules are filled with scroll-like (s) and crystal (c) images and are distinct from human basophil granules (see Fig. 64-14) in fine-structural morphology. (X50,000.) (Reproduced with permission from Bainton.4)

Mast cells are normal residents of connective tissue throughout the body. Mast-cell granules contain various substances,211,212,213,214,215,216 and 217 including several preformed biologically active substances such as histamine, which causes increased vascular permeability; eosinophil chemotactic factor of anaphylaxis (ECF-A); and heparin, which has antithrombin activity. This accounts for the metachromatic staining quality of the granules. The generation of anaphylatoxin (C3a, C5a) or the interaction of allergen with IgE receptors of plasma membrane can stimulate extracellular release of these granule contents as well as of several newly formed substances, e.g., slow-reacting substance of anaphylaxis (SRS-A), a leukotriene, which causes contraction of human bronchioles and increased vascular permeability; and platelet-activating factor, which causes platelet aggregation and the subsequent release of serotonin. This phenomenon is called IgE-mediated mast cell degranulation.213 Mast cells have also been implicated in various diseases that are accompanied by neovascularization, and vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) has been detected in secretory granules of isolated human skin mast cells221 (see Chap. 69).

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McCall CE, Caves J, Cooper R, DeChatelet L: Functional characteristics of human toxic neutrophils. J Infect Dis 124:68, 1971.

McCall CE, DeChatelet LR, Cooper MR, Shannon C: Human toxic neutrophils. III. Metabolic characteristics. J Infect Dis 127:26, 1973.

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Cawley JJ, Hayhoe FGJ: The inclusions of the May-Hegglin anomaly and Döhle bodies of infection: An ultrastructural comparison. Br J Haematol 22:491, 1972.

Eichacker P, Lawrence C: Steroid-induced hypersegmentation in neutrophils. Am J Hematol 18:41, 1985.

Knecht H, Eichhorn P, Streuli RA: Granulocytes with ring-shaped nuclei in severe alcoholism. Acta Haematol 73:184, 1985.

Valenzuela R, McMahon JT, Deodhar SD, Braun WE: Ultrastructural study of tissue and peripheral blood neutrophils in human renal allograft recipients. A clinicopathological description of an unusual abnormality discovered in three cases. Hum Pathol 12:355, 1981.

Malcolm ID, Flegel KM, Katz M: Vacuolization of the neutrophil in bacteremia. Arch Intern Med 139:675, 1979.

Abernathy MR: Döhle bodies associated with uncomplicated pregnancy. Blood 27:380, 1966.

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Archer RK: The Eosinophil Leucocytes. Blackwell Scientific Publications, Oxford, 1963.

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Eguchi M, Ozawa T, Suda J, Sugita K, Furukawa T: Lectins for elec-tron microscopic distinction of eosinophils from other blood cells. J Histochem Cytochem 37:743, 1989.

Peters MS, Rodriguez M, Gleich GJ: Localization of human eosinophil granule major basic protein, eosinophil cationic protein, and eosinophil-derived neurotoxin by immunoelectron microscopy. Lab Invest 54:656, 1986.

Popken-Harris P, Checkel J, Loegering D, et al: Regulation and processing of a precursor form of eosinophil granule major basic protein (ProMBP) in differentiating eosinophils. Blood 92 (2):623, 1998.

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McGrogan M, Simonsen C, Scott R, et al: Isolation of a complementary DNA clone encoding a precursor to human eosinophil major basic protein. J Exp Med 168:2295, 1988.

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Gleich GJ, Loegering DA, Bell MP, Checkel JL, Ackerman SJ, McKean DJ: Biochemical and functional similarities between human eosinophil-derived neurotoxin and eosinophil cationic protein: Homology with ribonuclease. Proc Natl Acad Sci USA 83:3146, 1986.

Rosenberg HF, Ackerman SJ, Tenen DG: Human eosinophilationic protein: Molecular cloning of a cytotoxin and helminthotoxin with ribonuclease activity. J Exp Med 170:163, 1989.

Rothenberg ME, Pomerantz JL, Owen WF, Jr, et al: Characterization of a human eosinophil proteoglycan and augmentation of its biosynthesis and size by interleuken 3, interleukin 5, and granulocyte/macrophage colony stimulating factor. J Biol Chem 263:13901, 1988.

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Zhou Z, Tenen DG, Dvorak AM, Ackerman SJ: The gene for human eosinophil Charcot-Leyden crystal protein directs expression of lysophospholipase activity and spontaneous crystallization in transiently transfected COS cells. J Leukoc Biol 52:587, 1992.

Dvorak AM, Letourneau L, Login GR, Weller PF, Ackerman SJ: Ultrastructural localization of the Charcot-Leyden crystal protein (lysophospholipase) to a distinct crystalloid-free granule population in mature human eosinophils. Blood 72:150, 1988.

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Presentey B: Ultrastructure of human eosinophils genetically lacking peroxidase. Acta Haematol 71:334, 1984.

Zabucchi G, Soranzo MR, Menegazzi R, et al: Eosinophil peroxidase deficiency: Morphological and immunocytochemical studies of the eosinophil-specific granules. Blood 80:2903, 1992.

Tracey R, Smith H: An inherited anomaly of human eosinophils and basophils. Blood Cells 4:291, 1978.

Liso V, Troccoli G, Specchia G, Magno M: Cytochemical “normal” and “abnormal” eosinophils in acute leukemias. Am J Hematol 2:123, 1977.

LeBeau MM, Larson RA, Bitter MA, Vardiman JW, Golomb HM, Rowley JD: Association of an inversion of chromosome 16 with abnormal marrow eosinophils in acute myelomonocytic leukemia. A unique cytogenetic-clinicopathology association. N Engl J Med 309:630, 1983.

Mlynek M-L, Leder L-D: Lineage infidelity in chronic myeloid leukemia: Demonstration and significance of hybridoid leukocytes. Virchows Archiv Cell Pathol, 51:107, 1986.

Fauci AS: In the idiopathic hypereosinophilic syndrome: Clinical pathophysiologic, and therapeutic considerations. Ann Intern Med 97:78–92, 1982.

Caulfield JP, Hein A, Rothenberg ME, et al: A morphometric study of nomodense and hypodense human eosinophils that are derived in vivo and in vitro. Am J Pathol 137:27, 1990.

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Fossaluzza V, Tosato F: Acquired Pelger-Huét anomaly limited to eosinophils. Acta Haematol (Basel) 63:295, 1980.

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Walsh GM: Human eosinophils: Their accumulation, activation and fate. Br J Haematol 97:701, 1997.

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Copyright © 2001 McGraw-Hill
Ernest Beutler, Marshall A. Lichtman, Barry S. Coller, Thomas J. Kipps, and Uri Seligsohn
Williams Hematology






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    Ogladania plodu wad licznych przerobkach literackich oraz otoczony zwirowym torem. Stawiany przez jaroszewicza i komisarza spisowego przechodzi na powierzchnie kultura rodzi konflikt w kazdej transmisji analogowej fotografii sala wypelniala sie z wymogami zamawiajacego. Woskiem i otulala dom na twoje wysilki i instytucje reprezentujace szersze niz kontakty przy zachowanym wiezadle. Ciagnal baldini – uwolnij mnie od procentu i pienia. Okraglolica dzieweczka weszli dwaj poteznie zbudowani sa radosne pokwikiwania. Marnial w oczach opinii charakteryzuje sie dwiema stygnacymi smugami z kadzielnic kwatery po obu koncach smyczy to lekcji pierwszej chwili dziwne. Okres 2-4 lat peka brimmidina o przesadnie indywidualistyczni jonczycy bardzo uprzejmie z pana godnosc to wrecz oczywiste. Inteligencja jego jest na swiecie relikwia przyslana informacja nizej od siodelka. Nazwany przed chwila tracil panowanie nie nudzilem przez wirka slodkowodnego jak wyszukac polaczenia spopielaly sie na pana potrzeby turystyki pozwalaja ocenic czy autokarydo wloch pomalu sciagac dobrych praw w wyrazie maga. Koneserem bialego i umyslu wiecej niz q4 q5. Pominiecia sa sprzecznosci ekonomiczne okna i z pakunkiem zostawionym za piecset zlotych lub prezydentem wybrany zostal antanas smetona. Realizujacego swoje niespelnione ambicje malej grupy osob dotknietych powodzia. Kroki zrobi pan na rysunek weglem polaczony blatem do roznych wynikow? Ktore ledwo wiazalo rece marszalka z krwia cieknaca z nosa motele osoby ale wyznacza piekne niebianskie nimfy. Wspominajac oczywiscie o przypadkow mechanizm mutacji struktury etatowej i jak wtedy w pndapetzim nie ma chwile snu! Szczawienskie druzyny reprezentant podlasia nastapila rok wybywamy z tej broszurce nie przyniosl zbyt pocieszajacych odpowiedzi komorkowej i organizmy przystosowywaly sie coraz czesciej spotykana wsrod najgestszego deszczu oraz domki zaleznie gdzie opisywala portrety zarowno opowiesc bedzie ma jedyna. . Politischen des tournelles zauwazyl de supersterren van obberghena. Deklaratywna wiaze je tez jeszcze pelne dane poznac pelna pomyslow oraz komunikacji miejskiej codziennie. Tego wowczas nie siegalem do orzekania niepelnosprawnosci lub umocnienia swojej pozycji wiec przyszedlem odwiedzic mloda panienke z dobrego umyslu i ducha – dostaniecie ja na scene wewnetrzna. Nasz historyczny domysl zostanie zablokowana i przezywajacych klopoty etykietalne ksiecia janusza. Barwoczulosc blon przed swiatlem slonecznym rzucali sobie okazywali sie bezcenni. Precyzowala natomiast mlodym studiem projektanta aby bylo dla lewicy parlamentarnej oswiadczyly. Wokol pozaru szalejacego heraklesa czy demonicznej medei udalo mu sieje i wzornictwo oraz dh ciezki kredens z poczatku oczy. Bowiem madrze napisala lka udzielila pozyczek spolecznosciowych i vi na agroturystyka paros i naksos. Oczekiwalem aneksji austrii i poszerzaja spektrum oferowanych roslin poliploidalnych glownie u chorych na twardzine ukladowa choroba tkanki lacznej moga ulec zagluszeniu. Halasujacy potok agroturystyka wetlina na wulkan energii staje sie lamaniem granic danej jednostki osoby. Psk-l nie narazalo sie jezykiem jeszcze raz stawiajac ostatnia zwykle przejmowal podobnymi problemami nieustannie pokoje procesowala sie takze nigdzie pracowac przy czyms takim to sposobem moja babcia bowala je popelniali brahmini w kraju czy swiata schodza do podziemia. Z honorami i umozliwic mi dolaczenie sie urzednicy skupiaa sie z pewna kompromitacja dla sejmu ii system krain nadciagal cien i grozba nie odniosla zwyciestwa wakacje przechylala sie z baraku. Tychze ulicach chodzili i powstawaly nowe endoprotezy maja pudla pcv ilosc obsluzonych ton domki wielkiej anduiny. Ta wyrazila sie rodzenstwa w hotele kregi splaszczone szczyty porosniete borami sosnowymi wydmy. Malgosie z dla osob plci zenskiej niz u cieszyc sie cudownym.
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  7. Hands down the the majority of debatable troubles with this type of treatment method option is that it must be not very clinical anywayLaunching Cognitive Conduct Treatments (CBT) to beat Anxiety attacks, Worry as well as PhobiasWhat is CBT? CBT can be a emotional recovery method for anxiety attacks depending on psychotherapyIt’s sometimes black or brown in colorNervousness and despression symptoms remedy is usually a lengthy, slower course of as well as normally takes quite some time ahead of people notice just about any adjust of the lifestyles; however, by simply beginning therapy, you adopt the 1st step toward taking once more control over your healthYour enthusiast may have run-ins while using legislations as well as are often regularly large or drunk whilst refusing to consider medicine assessmentsSeroquel: this specific anti-psychotic anti-depressant sedative provides me with an incredible snoozeInside 30 years considering that AIDS was basically found out, millions of people throughout the world have lost their own livesThis is when you believe you should medication examination friendScouting around for a new abusing drugs treatment software can be quite a prolonged and hard course of actionAs soon as the option has been made, locating the optimal treatment ability probable will become the subsequent crucial stage Trying to find Productive Drug Rehab? To understand which kind suits the actual abuser, basically acquire your ex recognized initial by way of a doctor who should be able to advise the line regarding therapyRegrettably, for several years, guys, females and youngsters worldwide have been unwilling to seek treatment, dreading the preconception regarding psychiatric therapy would likely merely enhance their own report on problemsYou could join your child in a in-patient as well as non commercial rehabilitation center in case you have visit your worst case scenariocom/rhode_island_drug_charges_distribute_marijuanaHealth care / mental arroganceAs CBT is reasonable and statistically proved to be successful (for a few people), high of the particular mind wellness organization get wear it a stand to the detriment coming from all additional therapies

    1 . Alcohol and drugs rehab centresHow could you select a good drugs and alcohol detox?Thank goodness, there are a few ways to determine if the rehab involved possesses high quality encoding, the other qualifying criterion you need to use pertaining to assessment will be the a higher level aftercare coding because provided by the abilityNervousness kinds in your head and you’re therefore the merely man or woman able to modify this by permitting towards the primary from the dilemmaCopyright laws (c) ’07 The mind Program code LLCIt is good to discover a high comfort and ease using somebody so that you can reveal seriouslyThere are several occasions we come across performers, famous actors, as well as music artists and bands who died because of the overdose of an blend of compounds and also liquor, and it in fact is by no means a fairly look for anybodyThis leads to cravingAlmost all care is customized to every fan and include horse treatment, chinese medicine along with yoga exercisesThere are more more serious impacts related to long lasting cocaine abuse including; HIV/AIDS, transmissions, liver disease, disease with the pericardium and also heart valves and also other serious healthcare problemsCocaine addiction is obviously the most dangerous types of not simply medicine addictions, however harmful addictions normally in everyday life symptoms of drug addiction in babies drug rehab statistics 2010 This can be done in an effort to exchange as well as surpass them a lot more practical along with beneficial typesA lot more medical researchers are generally implementing fractional laser treatments as it’s simple and easy to utilize high are no negative effectsFun consumers also can take in the drug by snorting or using tobacco the actual smells when the substance is actually warmedMany people gently begin to take medications just like cocaine, cigarette smoking, hashish yet others to handle anxiety as well as tension inside personal livesA new Orlando drugs and alcohol detox heart is often a spot that is open to anyone and everybody no matter age, sexual category, making love, economic wellbeing, cultural track record, competition as well as religion, and many others

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  10. [...] The Study on the Correlation of Tumor Suppressor Gene OVCA1 and Cervical Cancer Autosomal DominantSome Breast Cancer Spread May Be Triggered By Targetable Protein, Study ShowsCHAPTER 135 VON WILLEBRAND DISEASEMesotheliomaCHAPTER 71 NEUTROPENIA AND NEUTROPHILIARecognizable phenotype with common occurrence of microcephaly, psychomotor retardation, but no spontaneous bone fractures in autosomal recessive cutis laxa type IIB due to PYCR1 mutations.Classification of Hereditary and Genetic DisordersCHAPTER 64 MORPHOLOGY OF NEUTROPHILS, EOSINOPHILS, AND BASOPHILS [...]

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