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DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF PATHOPHISIOLOGY
Methodical recommendations
for independent work of English medium students of Pharmaceutical
faculty for preparing to practical classes by the theme
“LEUKOSES”
on the discipline “Pathological Physiology”
Lviv 2011
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DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF PATHOPHISIOLOGY
METHODICAL RECOMMENDATIONS
for independent work of English medium
students of Pharmaceutical faculty
for preparing to practical classes by the theme
“LEUKOSES”
Subject
Module # 2
Thematic module # 1
Year of study
Faculty
Pathological Physiology
Pathology organs and sistems
Pathology of blood
2-3
Pharmaceutical
Lviv 2011
2
Methodical recommendations made by: prof. Regeda M. S., as. Sementsiv N.G., Baida M.L.,
PhD; ass. prof. Lubinets L.A., Kathmarska M.O.
In the methodical recommendations for independent work of English medium students of
Pharmaceutical faculty for preparing to practical classes by the theme “Leukoses” main theoretical
information necessary for understanding of the material are given in full volume and according to
the study program “Pathological Physiology”.
Responsible for edition:
First prorector on scientific-pedagogical work
of Danylo Halytsky Lviv National Medical University acad. Gzhegotsky M.R.
Reviewers:
Associate professor
of the department of pathological anatomy
with the course of forensic medicine
of Danylo Halytsky Lviv National Medical University
Vovk V.I.
Associate professor
of the department of pharmacology
of Danylo Halytsky Lviv National Medical University
Gavryluk I.M.
Confirmed by medical commission on medico-biological disciplines
of Danylo Halytsky Lviv National Medical University
Protocol №3 from September 1, 2011
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LEUKOSES
I. SIGNIFICANCE OF THE THEME
Leukoses are the most common diseases of the hematopoietic system – they make 40% of the
total pathologies of blood. Increasing morbidity and mortality rate of leukoses is due to
progressively rising incidence of acute leukoses which make up almost 60% of all hematologic
cases. According to the data of the WHO, there has not been established any prevalence of
leukoses in either the part of the world or the groups of population , that is, leukoses occur in all
countries of the world and at any age, whereas contemporary methods of treatment for leukoses
have not proved sufficiently efficacious. In addition, certain aspects of etiology and pathogenesis
of leukoses seek for further clarification. Ensuing from the aforementioned, the problems
concerning leukocytoses can be claimed of a great significance and their study is viewed as an
important integral part of medical education.
Epidemiology
The incidence of leukaemia of all types in the population is approximately 10/100 000 per annum,
of which just under half are acute leukaemia. Males are affected more frequently than females, the
ratio being about 3:2 in acute leukaemia, 2:1 in chronic lymphocytic leukaemia and 1.3:1 in
chronic myeloid leukaemia. Geographical variation in incidence does occur, the most striking
being the rarity of chronic lymphocytic leukaemia in the Chinese and related races. Acute
leukaemia occurs at all ages. Acute lymphoblastic leukaemia shows a peak of incidence in the 1-5
age group. All forms of acute myeloid leukaemia have their lowest incidence in young adult life
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and there is a striking rise over the age of 50. Chronic leukaemias occur mainly in middle and old
age.
Aetiology
The cause of the leukaemia is unknown in the majority of patients. Several factors, however, are
associated with the development of leukaemia and these are listed in scheme
Terminology and classification
In acute leukaemia there is proliferation of primitive stem cells leading to an accumulation of
blasts, predominantly in the bone marrow, which causes bone marrow failure. In chronic
leukaemia the malignant clone is able to differentiate, resulting in an accumulation of more mature
cells.
Leukaemias are traditionally classified into four main groups:




acute lymphoblastic leukaemia (ALL)
acute myeloid leukaemia (AML)
chronic lymphocytic leukaemia (CLL)
chronic myeloid leukaemia (CML).
FACTORS ASSOCIATED WITH THE DEVELOPMENT OF LEUKAEMIA
Ionising radiation
 A significant increase in myeloid leukaemia followed the atomic
bombing of Japanese cities
 An increase in leukaemia was observed after the use of radiotherapy for
ankylosing spondylitis and diagnostic X-rays of the fetus in pregnancy
Cytotoxic drugs


These, particularly alkylating agents, may induce myeloid leukaemia,
usually after a latent period of several years
Exposure to benzene in industry
Retroviruses

One rare form of T-cell leukaemia/lymphoma appears to be associated
with a retrovirus similar to the viruses causing leukaemia in cats and
cattle

There is a greatly increased incidence of leukaemia in the identical
twin of patients with leukaemia
Increased incidence occurs in Down's syndrome and certain other
genetic disorders
Genetic

Immunological

Immune deficiency states (e.g. hypogammaglobulinaemia) are
associated with an increase in haematological malignancy
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The diagnosis of leukaemia is usually suspected from an abnormal blood count, often a raised
white count. The diagnosis is made from examination of the bone marrow. This includes the
morphology of the abnormal cells, analysis of cell surface markers (immunophenotyping), clonespecific chromosome abnormalities and molecular changes. Not only does this allow an accurate
diagnosis but also gives valuable prognostic information, allowing therapy to be tailored to the
patient's disease.
The World Health Organization (WHO) classification of tumours of haematopoietic and lymphoid
tissues divides these diseases into lineages and incorporates results from immunophenotyping,
genetic and molecular analysis.
ACUTE LEUKAEMIA
There is a failure of cell maturation in acute leukaemia. Proliferation of cells which do not mature
leads to an accumulation of useless cells which take up more and more marrow space at the
expense of the normal haematopoietic elements. Eventually, this proliferation spills into the blood.
Acute myeloid leukaemia is about four times more common than acute lymphoblastic leukaemia
in adults. In children the proportions are reversed, the lymphoblastic variety being more common.
Investigations
WHO CLASSIFICATION OF ACUTE LEUKAEMIA
Acute myeloid leukaemia with recurrent genetic abnormalities
 AML with t(8;21) gene product AML/ETO
 AML with eosinophilia inv(16) or t(16;16), gene product
CBFβ/MYH11
 Acute promyelocytic leukaemia t(15;17), gene product PML/RARA
 AML with 11q23 abnormalities (MLL)
Acute myeloid leukaemia with multilineage dysplasia
 e.g. Following a myelodysplastic syndrome
Acute myeloid leukaemia and myelodysplastic syndromes, therapy-related
 e.g. Alkylating agent or topoisomerase ll inhibitor
Acute myeloid leukaemia not otherwise specified
 e.g. AML with or without differentiation, acute myelomonocytic
leukaemia, erythroleukaemia, megakaryoblastic leukaemia, myeloid
sarcoma
Acute lymphoblastic leukaemia
 Precursor B ALL
 Precursor T ALL
CHRONIC MYELOID LEUKAEMIA (CML)
Chronic myeloid leukaemia is a myeloproliferative stem cell disorder resulting in proliferation of
all haematopoietic lineages but manifesting predominantly in the granulocytic series. Maturation
proceeds fairly normally. The disease occurs chiefly between the ages of 30 and 80 years, with a
peak incidence at 55 years. It is rare, with an annual incidence in the UK of 1.8/100 000, and
accounts for 20% of all leukaemias. The disease is found in all races. The aetiology is unknown.
Cytogenetic and molecular aspects
Approximately 95% of patients with CML have a chromosome abnormality known as the
Philadelphia (Ph) chromosome. This is a shortened chromosome 22 and is the result of a
reciprocal translocation of material with chromosome 9. The break on chromosome 22 occurs in
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the breakpoint cluster region (BCR). The fragment from chromosome 9 that joins the BCR carries
the abl oncogene, which forms a chimeric gene with the remains of the BCR. This BCR ABL
chimeric gene codes for a 210 kDa protein with tyrosine kinase activity, which plays a causative
role in the disease, influencing cellular proliferation, differentiation and survival. In some
apparently Ph chromosome-negative patients, the BCR ABL gene product is detectable by
molecular techniques.
Natural history
The disease has three phases:



a chronic phase, in which the disease is responsive to treatment and is easily controlled,
typically lasting 3-5 years
an accelerated phase (not always seen), in which disease control becomes more difficult
blast crisis, in which the disease transforms into an acute leukaemia, either myeloid (70%)
or lymphoblastic (30%), which is relatively refractory to treatment. Blast crisis occurs at a
rate of 10% per year and is the cause of death in the majority of patients. Patient survival is
therefore dictated by the timing of blast crisis, which cannot be predicted.
CHRONIC LYMPHOCYTIC LEUKAEMIA (CLL)
This is the most common variety of leukaemia, accounting for 30% of cases. The male to female
ratio is 2:1 and the median age at presentation is between 65 and 70 years. In this disease B
lymphocytes, which would normally respond to antigens by transformation and antibody
formation, fail to do so. An ever-increasing mass of immuno-incompetent cells accumulate, to the
detriment of immune function and normal bone marrow haematopoiesis.
Clinical features
The onset is very insidious. Indeed, in around 70% of patients the diagnosis is made incidentally
on a routine full blood count. Presenting problems may be anaemia, infections, painless
lymphadenopathy and systemic symptoms such as night sweats or weight loss. However, these
more often occur later in the progress of the disease.
Investigations
The diagnosis is based on the peripheral blood findings of a mature lymphocytosis (> 5 × 109/l)
with characteristic morphology and cell surface markers. Immunophenotyping reveals the
lymphocytes to be monoclonal B cells expressing the B-cell antigens CD19 and CD23 with either
kappa or lambda immunoglobulin light chains and, characteristically, a T-cell antigen, CD5.
Other useful investigations in CLL include a reticulocyte count and a direct Coombs test as
autoimmune haemolytic anaemia may occur Serum immunoglobulin levels should be estimated to
establish the degree of immunosuppression, which is common and progressive. Bone marrow
examination by aspirate and trephine is not essential for the diagnosis of CLL, but may be helpful
in difficult cases, for prognosis (patients with diffuse marrow involvement tend to do worse) and
to monitor response to therapy. The main prognostic factor is stage of disease ; however, newer
markers such as CD38 expression, mutations of IgVH genes, and cytogenetic abnormalities of
chromosome 11 or 17 may also suggest a poorer prognosis.
Management
STAGING OF CHRONIC LYMPHOCYTIC LEUKAEMIA
Clinical stage A (60% patients)
 No anaemia or thrombocytopenia and less than three areas of lymphoid
enlargement
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Clinical stage B (30% patients)
 No anaemia or thrombocytopenia, with three or more involved areas of
lymphoid enlargement
Clinical stage C (10% patients)
 Anaemia and/or thrombocytopenia, regardless of the number of areas
of lymphoid enlargement
II. CONCRETE TEACHING GOALS
Students have to gain knowledge of:
1. Definitions of leukoses, their etiology and pathogenesis.
2. Principles of classification of leukoses; kinds of acute and chronic leukoses.
3. Hematological characteristics of acute and chronic leukoses.
4. Criteria for differentiation between acute myeloblastic leukosis and chronic lympho- and
myeloleukosis. Students have and to be able to differentiate them by the data of hemogram
of patients with leukoses.
5. General disorders in the organism in leukoses.
6. Basic principles of the therapy of leukoses.
III. BASIC KNOWLEDGE, CAPABILITIES AND SKILLS ESSENTIAL TO THE
STUDY OF THIS THEME (interdisciplinary integration).
Names of
subjects
Histology
previously
Normal physiology
studied
Obtained knowledge and skills
Kinds of leukocytes and specific features of their structure.
Kinds
of
leukocytes,
their
functional
characteristics.
Differentiation of the individual kinds of leukocytes.
Calculation of the number of leukocytes and components of
leukoformula in the norm.
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IV. ASSIGNMENTS FOR INDEPENDENT WORK TO BE DONE WHILE PREPARING
FOR THE PRACTICAL CLASS
1. Basic terms, parameters and characteristics necessary to learn while preparing for the
practical class
Term
Hemoblastosis
Definition
The disease characterized by clonal neoplasms which
originate in the hematopoietic cells.
Leukosis
The systemic hematologic disease of tumoral origin with
inevitable
affections
of
the
hematopoietic
tissue,
development of extramedullar foci of hematopoiesis, and
appearance of blast cells in the peripheral blood.
Lymphomas
The generalized term used to define tumours which develop
from lymphoid cells located mostly outside the bone marrow
(in the lymph nodes, spleen, aggregations of lymphoid tissue
in various organs – intestines, nasal sinuses and others).
Lymphogranulomatosis
The malignant tumoral disease of the lymphatic system with
the formation of polymorphic cellular granulomas which
contain
atypical
polynuclear
cells
(Berezovsky-Ridd-
Shternberg cells) of unclear genesis
2. Theoretical questions for the practical class
1. Concepts of hemoblastoses and characteristics of their major groups.
2. Definitions of leukoses and principles of their classification.
3. The main etiologic agents of the genesis of leukoses, their characteristics.
4. Typical processions and peculiarities of the development of leukoses.
5. Morphological, cytogenetic, cytochemical and immune phenotype characteristics of
leukoses.
6. Peculiarities of the peripheral blood picture in acute and chronic forms of leukoses.
7. Hematological characteristics of acute myeloblastic leukosis.
8. Hematological characteristics of chronic myeloblastic leukosis.
9. Hematological characteristics of lympholeukosis.
10. General disorders in the organism in leukoses.
11. Principles of diagnosis and treatment of leukoses.
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V. CONTENT OF THE THEME: Structure-logical scheme 1 (after O.V.Byts, 2001)
LEUKOSIS
CHRONIC
ACUTE
Megakaryo
-cytic
Monocytic
Erythromyelosis
Lympholeukosis
Myeloleukosis
Monoblastic
Erythromyelosis
Lymphoblastic
Myeloblastic
Nondifferrentiated
Classification
Etiology
Oncogenic viruses
Chemical cancerogens
Genetic anomalies
Ionizing irradiation
Pathogenesis:
Gene mutation or epigenomic impairment of the regulation of division and differentiation of cells of class I-IV hematopoiesis
main links
Metastasis of leukemic
cells in the system of blood
Nuclear shift to the left
Cellular content depending on
the kind and stage of leukosis
Auto-allergic
reactions
Concomitance of
secondary infection
Reduction of
antibody production
Disorders of functioning of the
immune and associated systems
Reduction of
phagocytic activity
of leukocytes
Nonadherence to
cytostatic therapy
Leukemic
infiltration of the
non-hematopoietic
organs
Tumoral progression (transformation of monoclonal
stage into polyclonal)
Blastic crisis
Thrombocytopenia,
hemorrhagic
syndrome
Anemia
Disorders of normal
progenitors of
hemocytopoiesis
Inhibition of normal
leukocytopoiesis
Enhargement of
lymph nodes,
spleen and liver
Change of
hemogram
Formation of the clone of leukemic cells in the bone marrow
Change of
myelogram
Clinical
manifestations
Blastic crisis
Mechanism of
appearance
mechanism of
developmen
Atypical cells;
degenerative changes
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3. Assignments for practical work to be done in class.
Assignments
Instructions for the assignments
Calculate and write down leukogram. Depict Divide blood smear into the 4 imaginary fields
blood picture.
and, moving the smear in the broken line, count
25 leukocytes in each of them, Calculate the
individual kinds of leukocytes with the use of
calculator.
Make a diagnostic conclusion on the kind of
.
leukosis on the basis of the data of leukogram.
VI. MATERIAL FOR SELF-CONTROL
A. Assignment for self-control
Assignments
Instructions for the assignments
Give an account of causes and mechanisms of
Focus on the theoretical concepts of the
the development of leukoses.
genesis of leukoses and give the facts which
confirm these concepts.
Give classifications of leukoses.
Give the principles on which classification of
leukoses is based.
Give an account of the main manifestations of
Give at least three of them.
tumour progression in leukoses.
Give characteristics of acute and chronic Indicate peculiarities of the peripheral blood
leukoses.
picture in acute and chronic leukoses.
B. Tasks for self-control
Task 1. Patient B., aged 38, for the last year noticed growing fatigue and general malaise. After the
blood analysis, he was directed to the inpatient clinic. Blood count: E – 4.1 x 1012/l, Hb – 119 g/l,
RCI – 0.87. reticulocytes 0.7%. Leukocytes – 57 x 109/l. Leukoformula: B – 0%, E – 0%, J.n. – 0%,
R.n. – 0%, S.n. – 9%, lymphoblasts – 7%, lymphocytes – 81%, M – 3%. Thrombocytes – 160 x
109/l. In the blood smear: normochromia, large amounts of shadow cells (Botkin-Humprecht cells).
Which pathology of the hematopoietic system is this hemogram indicative of?
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Task 2. Patient B., aged 26, was hospitalized for excudative pleurisy. In the anamnesis: relapsing
quinsy, bronchopneumonia, furunculosis. Objectively: pallor, enlarged but painless and
not
coalescent lymph nodes (cervical, mandibular, axillary, inguinal), enlarged spleen and liver, rightside excudative pleurisy. Blood count: E – 2.8 x 1012/l. Hb – 90g/l. Leukocytes – 100 x 109/l.
Leukogram: B – 0%, E – 1%, C – 9%, lymphoblasts – 1%, prolymphi\ocytes – 5%, lymphocytes
80%, monocytes – 4%. Thrombocytes – 160 x 109/l. ESR – 25 mm/hr. In the blood smear: prevailing
micro-generations of lymphocytes, large amounts of shadow cells (Botkin-Humprecht cells).
Explain the mechanism of changes of the amount of leukocytes in this patient.
Task 3. Patient T., aged 54, sought medical advice for pains in the left hypochondrium. About 3
months before he had noticed increasing fatigue and general malaise. He assumed that they were due
to his overexertion at work. Blood count: E – 3.5 x 1012/l, Hb – 110g/l, RCI – 0.94. Leukocytes – 23
x 109/l. Leukoformula: B – 4%, E – 6%, myeloblasts – 2%, promyelocytes – 8%, myelocytes – 16%,
J.n. – 20%, R.n. – 16%, S.n. – 12%. L – 12%, M – 4%. Thrombocytes – 160 x 109/l. In the blood
smear: normochromia, anisocytosis, poikilocytosis. Reticulocytes – 0.4%.
Give characteristics of the detected pathology:

by the imparted hematopoietic progenitor;

by the degree of cellular maturity of the impaired progenitor;

by the number of leukocytes in the peripheral blood.
Task 4. Patient A., aged 42, was hospitalized for general malaise, fever, pains in the bones and
joints. Blood count on admission: E – 2.8 x 1012/l, Hb – 84 g/l, RCI – 0.9. Reticulocytes – 0.4%.
Leukocytes – 82 x 109/l. Leukoformula : B – 0%, E. – 0%, myeloblasts – 68%, S.n. – 20%, L – 10%,
M – 2%. Thrombocytes – 142 x 109/l. In the blood smear: normochromia, anisocytosis,
poikilocytosis.
Which classes of hematopoietic cells are probable sources of the tumoral clone in this case?
Task 5. Patient’s blood count: E – 3.6 x 109/l, Hb – 140 g/l, RCI – 1.0. Leukocytes – 30 x 109/l.
Leukoformula : B – 9%, E. – 8%, myeloblasts – 2%, promyelocytes -3%, myelocytes – 4%, J.n. –
1%, R.n. – 11%, S,n. – 43%, L – 15%, M – 4%. Thrombocytes – 210 x 109/l.
What is the mechanism of the pathogenesis of these changes?
Task 6. Female patient M., aged 17, sought medical advice for multiple hemorrhagic spots on the
skin. She had noticed separate spots before but hadn’t paid special attention to them as she viewed
them as signs of minor injuries. Blood count: E – 3.6 x 1012/l, Hb – 100g/l, RCI – 0.83. Leukocytes
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– 6.5 x 109/l. Leukoformula: B – 0%, E – 0%, J.n. – 0%, R.n. – 1%, S.n. – 18, lymphoblasts – 67%,
lymphocytes – 12%, M – 2%. Thrombocytes – 60 x 109/l. In the blood smear: normochromia,
moderate anisocytosis, poikilocytosis. Reticulocytes – 1.2%.
What is the pathogenesis of hemorrhages in this patient?
Task 7. Female patient K, aged 24, was hospitalized in a grave condition: increasing weakness,
retardation, high temperature (up to 39°C). bilateral pneumonia, petechial eruption on the skin.
Moderate enlargement of liver and spleen. Blood count: E – 1.2x 1012/l, Hb – 40 d/l, RCI – 1.0.
Leukocytes – 2.4 x109/l. Leukoformula: B – 0%, E – 0%, J.n. – 0%, R.n.. – 0%, S.n. – 2l, M – 6%,
blast cells – 57%. Thrombocytes – 89 x 109/l. In the blood smear: large, irregular blast cells with
large nuclei. By the main cytochemical characteristics, blast cells belong to the cells of monocytic
line.
1. What is the diagnosis of the pathology of the hematopoietic system in this patient?
2. What leukopoietic changes is the appearance of blast cells in the peripheral blood
indicative of?
3. Which cytochemical signs prove that blast cells belong to the cells of monocytic line?
Task 8. Patient B., aged 15, complains of recurrent seizures of pain in the shanks and soft tissues of
the forearms. Objective changes of the skin and configuration of extremities are absent. Blood count:
E – 2.3 x 1012/l, Hb – 60g/l, RCI – 0,8. Leukocytes 137 x x109/l. Leukoformula: B – 0%, E – 0.5%,
R.n.. – 0.5%, S.n. – 12%, L – 18%, M – 6%, blast cells – 63%. Thrombocytes – 140 x 109/l. In the
blood smear: large, irregular blast cells with distinctly vacuolized cytoplasm which contains rough
granulation. By the main cytochemical characteristics, blast cells belong to the cells of myeloid line.
1. Which hematopoietic pathology does this blood count indicate?
2. What is the mechanism of detected changes of the red blood cells?
Task 9. Patient’s blood count: E – 3.6 x 109/l, Hb – 140 g/l, RCI – 1.0. Leukocytes – 30 x 109/l.
Leukoformula: B – 1%, E – 3%, J.n. – 0%, R.n.. – 4%, S.n. – 43%, L – 15%, monoblasts – 2%,
promonocytes -3%, M – 14%.Thrombocytes – 210 x 109/l. In the blood smear: atypical monocytes
with nuclear fragmentation.
Which blood pathology are these hematopoietic changes characteristic of?
Task 10. Patient A., aged 22, was hospitalized for the complains of weakness, fever, hyperhydrosis,
pains in the throat on swallowing. Blood count: E – 30 x 109/l, Hb – 70g/l. Reticulocytes – 0.2%.
Leukocytes – 45 x 109/l. Leukoformula: B – 1%, E – 2%, blast cells – 79%, myelocytes – 0%,
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metamyelocytes – 0%, R.n.. – 0%, S.n. – 13%, L – 4%, M – 1%. Thrombocytes – 100 x109/l. ESR –
34 mm/hr. In the blood smear: anisocytosis, poikilosis, anisochromia.
What is the change of organism’s reactivity caused by?
Task 11. Patient presents with the poorly healing cavity after tooth extraction and sanies discharge
from the cavity. Blood count: E – 3.6 x 1012/l, Hb – 140g/l, RCI – 1.0. Leukocytes – 25 x 109/l.
Leukoformula: B – 8%, E – 8%, myeloblasts – 3%, promyelocytes – 2%, myelocytes – 3%, J.n. –
1%, R.n. – 12%, S.n. – 44%, L – 16%, M – 3%. Thrombocytes – 220 x 109/l.
Explain pathogenesis of this disease.
REFERENCES
1. Robbins Pathologic basic of disease. - 6th ed.-/ Ramzi S. Cotnar, Vinay Kumar,
Tucker Collins. – Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. –
1999.
2. Gozhenko A.I., Gurcalova I.P., General and clinical pathophisiolodgy/ Study guide
for medical students and practitioners. – Odessa, 2003.
3. Hematology. Basic Principles and Practice. -/ Ronald Hoffman, Edward J. Benz Jr.,
Sanford J. Shattil, and others . - Elsevier, Churchill, Livingstone. - 2005.
4. Harrison’s Manual of medicine .- 17th ed.- /Anthony S. Fauci, Eugene Braunwald,
Dennis L. Kasper, and others.- New York, Chicago, San Francisco, London,
Madrid, Mexico City, New Delhi, Sydney, Toronto.- 2008.
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