Transcription
Please allow your friends to enter the meeting, 'cause I cannot see the main screen. This is the case. The screen is visible, right? Yes, we can see that. Yeah. Okay. Right.
So, this is a 60-year-old lady with a pension. This is Power 10. This was a Power 10 view for this patient. And let's go to Power 15 now. This patient is severely ill, as you can see. Yeah. List the sides there. No platelets.
Hello, Mor is our senior biomedical scientist consultant. Morning, everyone. Morning. Nice over there. Pella sites. I have shown you multiple Power 15 possible TTP. Is the calculation screen done? Coagulation screen is normal. All right. Okay. Prominent nuclear there. All right. Would you like to refer this to a clinical hematologist or no? Oh, yeah, definitely. Yeah, this would be referred to definitely a suspicious blast there as well. Okay, but the TTP, well, sorry, a lot of shites there, but no nuclear RBCs. No, I I definitely refer this to the consultant. Okay, good point.
So, we need a volunteer to comment on this blood pin to report this blood pin from the clinical hematologist, 'cause the lab have referred this pin to you. I can go for this. Yes. So, report the blood. So, I'll start there is, um, um, red cellopytosis with multiple irregular contracted cells and, um, um, electroytes. Um, also, there is, um, clear thrombocytoenia. We, um, there is a population of mononuclear cells with high NC ratio, um, nucleus, open chromatin, a granular cytoplasm, and visible nucleolus, um, pilobed, spobed nucleus, if you can see it, a granular cytoplasm. So, I need, um, so this population of cytoplasm or of, um, um, blast cells are very suspicious. And descend for low side 23. Yeah. Okay. It's not clear if it is only indented or by lo. I need to look at for other. This is indention because indent. Okay. Uh, this side of the nucleus don't have a separate nuclear right? So, yes, everyone will send this blood for flow cytometry. But what is your impression? What will you to proceeding this blood? Close, you sent it yesterday, and it, it is now weekend. Monday is bank holiday. Mhm. And, um, the result will come [Music] on Monday, most likely if if someone has elaborated this to the HMDS. What do you think is going on here in this paper? M, um, coagulation is, coagulation profile is normal, but I think, um, yeah, so it is, I will call the patient to assess, see her clinically, if she's stable, and, um, patient is in the hospital because she's unwell, unwell. She has pancytopenia. She's feeling very tired like me, and she has bruising. She has recurrent infections. So, you have found out that you have commented on the component of the blood pin. What is your impression? Yes. Everyone, even if I give this patient this blood thin to hematology SHO, he will send, he will say that I will send his flow cytometry because he has noticed some abnormality in the blood. But I want you to make a report as a clinical hematologist because you will be sitting in the part two exam. Recent, uh, in the future. Yeah. What do you think is going on in this patient? That you want to confirm on why you want to send me to HMDS? Throughout leukemia. Um, your impression. So, your impression is, uh, likely acute leukemia because you, you cannot confirm things on peripheral blood. So, you will say most likely, uh, acute leukemia. Yeah. Send blood to HMDS for urgent and this patient bone marrow biopsy as well. Yes. Confirm the diagnosis. Mhm. So, the blood film shows transcyptopenia. Yes. But, but you will still not get full marks because you have not commented on the full features of this blood. As the, as your colleague mentioned that there are many. Yeah. In the red cell lineage, there is hypocromia in the red cell lineage as well. So, you need to commend on all the finding. Sure. Yeah. Because if I am your examiner in the part exam, I will have a list of u findings in the blood. So, I will see whether Ravia has mentioned hypocromia or not. Yes. One more. No, minus one. Ravia has mentioned in this one or toyopenia in this one. Yes. One mark. Low minus one. [Music] Why people fail in part two exam? Because they know the diagnosis. This is acute leukemia, but they don't know how to write it. How to write the report in the exam. Okay. When you appear in part exam and people come out in the center. Oh, say slide number one was acute AML. Slide number two was mental cell, and slide number three was TPL. But when the result came, they failed the exam because, yes, they know what is the diagnosis, they don't know how to report the blood. So, FRCAD exam is not a knowledge exam. It is a knowledge plus skill exam. Okay. Okay. So, you need to know the skill of the exam as well. Pass the exam, whatever, however you like. In the real life, if you want to say this is acute leukemia, that's it. No one will notice it. But for the exam purpose, you need to pass the exam. You have to write it like they want on the exam. Okay. Okay. Many brilliant people fail in the exam because they don't know the skills. Many average people pass the exam in first attempt because they know the skills of it. And better to, uh, write the report with your pen on a paper so that you have a practice because I know you're going for exam. Mhm. And there are a lot of morphology quiz slides on in our channel. Go through the slide in 3 minutes and write your report in part. You will have a good practice. Okay. So, this, this was acute myeloid leukemia on close and transmia. Always keep as your def, sorry, am I ask? Please, uh, you mentioned that, uh, if you missed a finding, you will be, uh, you will be, uh, having minor one. It's not zero. You will have minus. I mean, if thrombocytopenia has one mark, Mhm. You will not, you will not receive that mark. Okay. Yeah. Because you have not mentioned thrombocytopenia. So, if the report mark is six marks, you have written the diagnosis, everything, but you have not mentioned thrombocytopenia. You will not receive six marks. You will receive five marks. Five marks. Yeah. I thought that it's minus. So, you will receive four marks. No, no, there, there is no negative marking, but you will not get a mark for that thing. Yeah. Okay. [Music] He is right. Whatever he's saying. Yes.
This is the second case. This patient has, um, worsening petechiae and he is 60 years old. The GP has sent this patient to you to the hematology outpatient clinic because his anemia is worsening and his, um, symptoms, tiredness is worsening as well. The spot blood count shows white hemoglobin of 102, white cell count of four, platelet count of 155. This blood film goes to a biomedical scientist first. This is Power 10 over here. And now let's go to 50. These whites out. Few kind of sites there as well. So, what do you think as a biomed scientist, I should say consultant? Sorry. Yeah. Um, it's a possibility is there, like liver, kidney problem here as well. Is LFT un been done? Yes, LFTs are normal. UA is normal. I am on the side for a reason. There seems to be projections on the Olympic to the top there. Yeah, I don't like that cell there. It's getting some two projections on it. What is your impression? Sorry, doctor. The patient was presented with what? Progressive anemia and fatigue. Yeah. Well, it's not a classic HCL, but I'd have to have a look. One more sound. The film does look a little bit on the older side. Is it like artifacts? Yes, it is ed artifact. Yeah, the liver and kidney function is okay. Would you like to refer this to? Um, little bit unhappy about some of the lymph, maybe lot of kindites. Yeah. Not happy with that cell there. Yeah. I, I, I'd let the consultant have a look. Okay. So, what is your impression and then refer to possible within projection? It's not, could be like SVL or I'm sorry, business or it could be HL. I definitely refer it, um, possibly send for flow. [Music] Sir, is there any stenome in this? This is 13 cm. Yes, sir. Yeah, that's a bit of concern. This is the picture at 100. Bit blurry. I think this cell has more hair than me. Right.
So, the film has been referred to hematology, clinical hematology. And who is going to report it? I can go for this one. Yes, please report the blood film. You are sitting in FRC Path exam. Okay. So, um, the blood film is showing, um, monomorphic population of, um, lymphocytes, um, with cytoplasmic projections and, um, nucleus, um, shows, um, dense chromatin, um, homogeneous dense chromatin, um, with slight, um, indentation. Um, the film also showing, um, anemia with, uh, mild microcytosis and, uh, some ruler formation. Um, we are, we are on the thick side, that's why there is ruler for. Mhm. Go on. Yeah. All right. And platelets, please, adequate. Um, yeah, I would like, so this is, um, I think I will, I will say, uh, picture is suggestive of LPD. I will send the sample for immunotyping to, to clarify, exclude what? So, this, um, to exclude or confirm hairy cell leukemia, um, or splenic marginal zone. Okay. Anyone disagree with this report? Looks like everyone agrees with you. Okay. So, whenever a patient has progressive, uh, anemia and there is splenomegaly, which may be present or may not be present, you should think about hairy cell leukemia. But you cannot say this is definite hairy cell leukemia, as you mentioned correctly, lymphoproliferative disorder is the correct term because you will confirm the things, um, close to me and, and the, um, bone biopsy in this patient. Maybe it's not very clear, but this one looks like whole jol and this one as well, but it's not very clear. Okay. I missed out. So, yes, correct. This is LPD and the close autometry was positive for hairy cell leukemia. So, whenever there is anemia or pancytopenia, always look the thick side as well, because our junior missed this case because they were only looking at the thin side of the film. We, uh, when we were in ST3, we were told as well that do not go to the thick side. Always focus on the thin side as well. No, look the thick side as well. The hairy cells are always hidden among the, uh, among the cells on the thick side of the blood. Okay. So, yes, this is hairy cell leukemia. You can see hairs all around the cells and in modular zone, splenic modular zone, the hairy cells will be at the end. Some here on this end and some hair on this end, which are called polarized hair. Polarized hair project. Okay. Right. What flow cytometry panel do you expect in this patient? So, I will run the LPD panel. Um, I will expect to see CD, uh, CD25, 11C, um, positive, CD 103 and 123, uh, positive. Um, yeah, um, and if it's a variant, hairy cell or or I would expect to see, um, 25 negative. There is no variant hairy cell now. It has been removed after WH 2022, and the variant hairy cells, they are a bit bigger with a prominent nucleoli and more cytoplasm, and they have leukocytosis. Their white cell count is high. I see. Okay. And if you want to give this patient treatment because his spleen is making him discomfort, giving him discomfort or anemia is worsening. What are the first-line treatment in hairy cell leukemia? So, the first line will be purine analogs, cladribine. Um, yeah, I think, uh, it's cladribine. Um, weekly for for five weeks. Yeah. Dripping. Yes. Perfect.
The third case is a bit difficult, but those who have sharp eyes may pick it. It's because the findings are a bit [Music] not clearly visible. Month. This patient is 19 years old and his fever is not responding to antibiotics. He received 2 days of IV antibiotics but he did not respond to it, and then he became confused. The blood cultures were negative. Viral serology was negative. CT scan was negative. Ferritin was not high. What was the HP? Sorry. The HP was 120. White cell count is low, as you can see. Little 55. Go to a bit abnormal. There is occasion like bite cells, DP or something like that. Expect to see more. He is a white guy. So G6PD, we did that, but he was not any history of trouble. Yeah. No. Yes. He went to India. Okay. We got to times 100. Are there some RMS? Yeah, I saw I saw something because it is not a typical presentation. I mean, the findings in the blood, it was missed initially, but then someone picked it in the lab. Is it falciparum malaria? Because there are some inclusions in the red cells, maybe, but they are very, very small, one. Yeah, they are small. Yes. They call for on the circumference of the red cell. Yes, the like the we have seen falciparum, but the rings are not that small like we say it covers 1/4 of the red cell. This is I think 1/10th of the red cell. They are so small, and they are so small that you cannot, you cannot distinguish clearly. No, I mean, it's more clear here. It was before like a single dot. Yeah. Yeah. There is a double chromatin in one of them. Yeah. And they are like bulging from the red cell as well. Yeah. The one in the center is a bit appearing as a ring form. Yeah, there's no, there's no dots. I can't see. Sorry. There was no gite even in the. No, the, the same, the size of the cells are the same. This is quite for falciparum. They're not enlarged. Yeah, nice round. And some has two as well. Oh, yeah. Yeah, you can get multiple infos for them. Yes, positive. The reference say this is interesting to see where they position though, because they're not usually like that. There are many people missed it. Even in our lab, many people missed it, uh, because of the Yes. But this patient has thrombocytopenia and he was not responding to, not responding to the antibiotics. Right. Then we could repeat the blood film and see why is that, and when we did the oddity, it was positive. H, yeah, it's not a clear one. They are small within the cell though, you know, bigger and, yes, sometime unusual presentation we can get for these. Bottom makes the cell size bigger, I think, right? Or no, not usually the same size. It doesn't, it is. The I think it's the Yex. Yex make the side the rest size bigger. Yeah, they make him a mean boy. They call the ugly, ugly parasites, and they're probably one of the easiest to diagnose. Yeah, this was the case of falciparum, and it was a bit unusual, and it was a delayed diagnosis as well in our hospital, but the person survived. He is okay now. His parasitemia was quite high, 29%. Yeah. But the tropical medicine did not say for red cell exchange. They say they have some new drugs now and they say give that medication to the patient, patient will recover, and he is okay. But was previously, now, what was the medication that they gave? I don't know about, but it was not the artemisinin which is usually given in the falciparum previously. We used to do the red cell exchange with this amount of parasitemia and with cerebral malaria. Cerebral malaria is an indication of red cell exchange, but they didn't do exchange. They gave him drug, and the next day patient was okay. I will check that drug, what was the name of the drug that I gave the patient. Okay. Thank you. It is not the usual, uh, it is something else. Was he having, uh, renal impairment as well? No, he had only fever and significant thrombocytopenia, and then on the third day, he developed confusion. Okay. We did CT scan for him, and the CT scan was normal. It's good that you ask about the travel history and you go for Power 100 as well. If you read the, uh, malaria guideline in BSH 2022, it says that if a patient has unexplained thrombocytopenia, you should consider malaria in your differential diagnosis as well. But obviously, a travel history is important. If he has traveled or someone in in his family has traveled recently abroad, he may have brought mosquito in the back.
This is the fourth case. This is a 55-year-old lady with progressive fatigue. Again, hemoglobin is 110, white cell count is 20, and platelet count is 155. This is over. Leukocytosis is probably neutrophilia. Let's go to 50 now. There's a few basophils around, which is a bit concerning. Mhm. You haven't seen Dr. How are the LFTs? LFTs were normal. What's the effort count? Count was three. Okay. Percentage? I know absolute. That I would not remember. It's only symmet. We're tempted to say it's possible CML. You think that they say possibly CML? Yeah, I send it for, I definitely refer to the consultant. Too many P of there for my liking. Dr. Ramir, does the patient have splenomegaly? Yes. Who was that? Who asked the question? Uh, Romano, you need to report this blood film then. Okay. So, um, the blood film shows leukocytosis, predominantly neutrophilia with some left shift, and then there are prominent basophils as well. Uh, the red cells show, uh, some of them show targeting. I could see some u sites as well, but targeting is prominent. And the platelets are, uh, I think, uh, yeah, they are adequate. This cell, the one that I'm looking at now is a bit suspicious, maybe having prominent nuclei, but I'm not sure about that. It might be a blast. Uh, so, with the background of splenomegaly as well, I think, uh, I'll send, uh, this is most likely, uh, myeloproliferative neoplasm, and, uh, I'll show, I'll, uh, send the BCR for this patient. Also, does the patient have any other infection? How was, how was the CRP? And no infection. Okay. So, I, I'll send, uh, I think for BCR ABL. BCR ABL. Yeah. Okay. Why you want to search for BCL? The cross to confirm if it is CML. Oh, all right. So, this patient has a lot of basophilia, eosinophilia, cube loss, neutrophils, and the u bend form as well with spleno megaly. This is most likely CML. You would send the blood for BCR, which came back as positive. Okay. So, what are the prognostic factors in CML? Uh, sorry, Dr. Amir, it's not on the top of my head at the moment. Anyone else? What are the prognostic factors in CML? Um, spleen size, CM block, and I think blast, uh, percentage in bone marrow can't remember very well. Sorry. The level of BCR ABL after 3 months and after 6 months or something else. What else? H count. Okay. What else? Dr. Can we, uh, we can, uh, get the prognostic, uh, score from the ELTS also. You toss the score that LTS is a score that we use in UK for the CML. So, always divide the prognostic scores into two: disease-related and patient-related. This patient has high ALTS score. It is a bad prognosis. Or you can say individually, this patient has low platelet count, high blood count, size is high, low HP. These are two prognostic. If major root abnormalities are present, this is a poor prognostic factor. Resistant to first-line treatment is a poor prognostic. If the patient is having multiple comorbidities, the patient performance status or comorbidity index is high. This is a poor prognosis. If the patient refuses treatment, this is, uh, a poor prognosis. Okay. So, prognostic factors are always disease-related and, uh, treatment-related. What are the major root of the CML additional Philadelphia? Um, from 8. Mhm. It's 3Q, um, deletion, monosomy 7, isochromosome 17, trisomy 8, 21, additional Philadelphia chromosome, 19, no, 21. And what are the first-line drugs in CML? That's it. You ask what are the first-line drugs in CML? I put the siblot can be used as first line as well. Oh, the certain. And when, when will you use the sertin as a first line? If we need, if we need to achieve, um, quicker response, um, then we can use the satin as a first line. For example, for young females, if she, she wants to get pregnant, or, um, if young and, um, having, uh, high-risk disease, and we need to go for stem cell transplant, then in that case, we can use the sativas first line. Yes, high LTS, high-risk disease to achieve remission quickly. These are the few indications of, uh, second TKI, does something, second generation TKI. All right.
This is the last case. This is a 20-year-old female with cervical lymphadenopathy. The full blood count was hemoglobin of 110, a white cell count of 14, and platelet count of 200. This is Power 10. Right, Mo, I think you are the only biomedical scientist who left with me. So, you have to commend. I will go to 50. There's a few, there's a bit of unnecess I get it. F shift there. Yeah. They're quite large mononuclear cells. Mhm. Not atypical mon size. What is your impression? It's probably possibly an infection with monocytosis, and, um, it's like a promyocytes, probably. Yeah, it's probably my, probably an infection, some form. Is the coagulation screen okay? Yes, coagulation screen is okay. CRP? CRP was 14, slightly elevated. There's a little bit of polychromia. Maybe it could be the stain helmet cell there. I'm sorry. What was the platelet count? Count was normal, 200. Right. Would you like to refer this to hematologist? [Music] Um, if I, in a normal situation with a number of neutrophils, they don't look abnormal. This patient has another right. Okay. Yeah. Yeah. Smear cell there. How old again? Sorry. 20-year-old. Right. See what this is. I'm inclined to go for infection, but, um, yeah, I can't see anything really. There's monocytosis, neutrophilia, PLS. Okay. Sometimes they'd be up in infection or low. Um, possibly slight polychromemia there. Patient's not really that anemic, is he? I can't see toxic granulation. Mhm. There was a prominent site there. So, did a left shift, but I can't see any myelocytes. About too sure if I would refer this. I'm not sure. I'd have to see a bigger field to be honest. Mhm. Yeah. I have to have a good look around at the sides as well, just to see if there's any cells accumulating at the periphery as well. Okay, let's refer it to hematology. Is it, um, continuous, uh, high this count? Is this count continuous? Has been high for a long time, or is it just the recent? Recent. There was no previous count to compare with. It's not a chronic in reality. Probably I would just say it's a neutrophilia, monocytosis, possible infection. Mhm. Just repeat to monitor. Let's take opinion from clinical hematologist. Let's see what this is. Yeah, Dr. Can I go ahead? Yeah, go ahead. So, uh, the blood film, uh, shows, uh, leukocytosis with prominent neutrophils, a bit of left shift, and then the monocytes also show signs of activation with vacuolation. There are some lymphocytes with, I could see some lymphocytes with abundant cytoplasm and scalloping around the red cells. And the red cells also show, um, anisocytosis with some elliptocytes, a bit of hypocromia, some teardrops, occasional, uh, fragmentation. Platelets look adequate. So, uh, I think on the basis of this morphology, it's most likely some infection. Uh, I would like to check for EBV infectious mononucleosis markers as well. If the patient has lymphadenopathy, patient has a sore throat. Okay. Patient has a sore throat and painful cervical lymphadenopathy, and you have seen a lot of activated monocytes, reactive lymphocytes. So, this is not leukemia. This is not myelomonocytic. This is just a simple infection, mononucleosis in the patient. Okay. If it was myelomonocytic, you would have seen a lot of monoblasts as well. And this patient is anemic. As you can see, there is a clear-cut hypocromia. Yes, leukemia can happen at at any age, but if the patient has sore throat or painful cervical lymphadenopathy, young age, then usually it is infection-related reactive lymphocytosis. One thing which I would like to mention here is that scalloping is, uh, not a feature of a reactive lymphocyte. We have seen many cases, um, in the previous sessions where there was a 19-year-old with monoblastic leukemia, 60-year-old with myelomonocytic AML. They had a lot of, uh, monoblasts in the blood film, and all of them were scalloping. So, do not tell your juniors that if a lymphocyte is scalloping, this is reactive, you may miss a diagnosis of leukemia. So, scalloping is not always a feature of reactive lymphocytes. It can be present in leukemias as well. I think we should come out of this, uh, scalloping related reactive lymphocytosis thing that if there is scalloping of the red cells, this is reactive. No, your colleague may miss a diagnosis of acute leukemia, and there will be a delay in the treatment of the. Okay. If a patient is having significant anemia, red loss, u promocytoenia, blood film is full of monoblasts and shows scalloping, I would say this is reactive. White cell count is 130. I would say this is reactive. It's not. So, do not misguide yourself and, uh, by by scalloping related thing. I have seen a lot of cases recently where they were having AMLs and they were having scalloping as well. This was the last case, and can you please share this thing with your medical colleagues? Okay, let's bleep hematology in a hope that the bleeds to the hematology team will reduce. Okay. Do you have any question? You can ask. Yes, please. Uh, can I ask, uh, regarding the case of AML with shift cells, does it carry a significance of associated? No. No. Or if the patient has infection or sepsis or DIC, then the patient will have schistocytes. If the patient has folic acid deficiency or B12 deficiency, a patient will have schistocytes. Schistocytes is not always a feature of TTP. If you see, if you see a folic acid deficiency patient, the patient will have a lot of schistocytes. It does not mean that this is TTP. Yes. Okay. Okay. Thank you. Thank you, Dr. Air. Nothing, then we'll stop here and enjoy. Thank you.