Transcription
Can you hear me?
Yes. Good morning. Good morning. And can you see the screen? The screen is visible.
Yeah, this is the first case. This is a 32-year-old female who has delivered a baby two weeks ago, presented with Epistaxis. Hemoglobin is 9.8, white cell count it's 12, and the platelet count is 110. This is power 10, just the overview of the film. Now I will go to power.
Any thoughts about what's going on?
There's one or two uh some possible blast cell maybe. I don't like you're in a thick pot here. There's a lot on this side because as well.
We'll go to thin side, but looks like they're more concentrated on the thick side.
Yeah, I don't like that sound. It's very reactive. Obviously thrombocyte. Well, the PL count was fine, wasn't it?
Yeah. 110.
Oh, it is a bit low then. Yeah. Yeah. I don't like that cell. Big nucleus, basilic cytoplasm, very large.
So, what would you do?
No, this is definitely a referral. I won't be happy letting this one go. The red cells don't react either. A picosytosis, tear drop, killer site there.
Mhm.
So, what was the HP again?
98.
That's low. Okay. No, they're not. So what the clinical hematologist will do. We have Emil Sabah. Sorry, what was the question?
So the biomedical consultant has referred this blood to you. What you will do with this?
Honestly, I was struggling seeing the blasts. If it was a blast, then I would feel it first. Definitely.
And
No, I mean, you are the clinical hematologist. The lab have seen the blood thin and they have kept it in your tray. You have come to the lab to see the blood thin. And these are the This is your blood thin in front of you. So I see I what I see is roller formation, accounttotes, teardrop cells, there is abnormal cell, but the color is not right, so I can't really tell whether these are blast or not. So I'm going to have to call if the patient is it's a GP block, then I have to call the GP and and take a history.
This is ED blood because the patient has come to us with bleeding in the ED department.
Now, she had the recent history of delivery.
Yeah, two weeks ago.
Weeks ago. This is nucleated red cell or?
Yes.
So nucleated red cell. Okay. And teardrop cells.
This is not a nucleated red.
Not this one. There is one that.
Not this one. Not this one. I've seen I've seen one.
Yeah.
This one.
Yes. This one.
Yes. Exactly. So I wonder if she's had lucidoplastic picture because I haven't seen any. Yes, with the teardrop sings. What do you think is this? This one the big one.
So it could be Yes. This is a blast.
Mhm.
I can't differentiate of course whether it's aoid or lymphoid. They have gran. Can you see the gran? I will make it big. Yes.
This is power 100. So they have a lot of.
Okay.
Go back to power 50. To report this blood thin.
How would I report it? So there is uh there is.
You're a clinical hematologist, right?
Yes.
So I've reported the the the red cell, the white cells. I would say there is increasing nucleoplasmic ratio of monomorphic cells.
Mhm.
Of monomorphic.
Right.
And and I have to count the blasts and see the percentage.
Mhm.
With granules and opin chromatine and I think that's all that I can see and then I will say the plate the platelets comment on the platelets where they um say like I will say that they are unremarkable.
And then I will say my impression that if the the blast count is more than well, I have to to see the percentage and then say suggestive of AML or and then I advise to send an urgent flow and then of course speak to the to the ED.
All right. So you have seen many blast in this blood pin. You would say this blood can contain multiple blood because all the cell has multiple nuclei. This is one, two, three, four nuclei are present and the other blast have the same number of nuclei present. Then the red cells are quite abnormal. There are teardrop cells. There are histoes even and one or two cells have the our jolly bodies are very and therefore NRBC counts are low and has anis. You have commented on all the three cell line targeting the the main one first, the blast are prominent. You have commented on the blast. Your impression is acute leukemia. You do not say that this is acute myoid leukemia or lymphoid leukemia on a blood film because you wait for the flow result. Flow can be anything. It can tell you that this may be biophenotmic biohenotypic uh leukemia. Okay. Because the main population in front of us is granular, but it can be anything. That's why we only say this blood thin is uh suspicious for leukemia. We need urgent flow for this patient and admission under hematology. Patient is bleeding. There are blasts, chromosymia, anemia. So this patient have AML provisional flu report comes within 1 to two hours and my trust. Okay, we send it to HMDS. Ask them we need provisional flow. They they send us provisional report and tell us within 1 hour or 2 hour that where are we heading. These are my loss volume. We call it as AML okay because the blast percentage yes, morphologically it matters. It could be about more than 20%. But these days loss percentage does not matter if you have uh specific genetic mutation except for two PCR ags. Percentage doesn't matter. So you have to report it. Do you have any question?
Yeah, I've always wondered why they put the percentage greater than 20% for leukemia. I mean, there shouldn't be any blasts in any peripheral film anyway. How do they decide that level?
So morphologically, if if you have not sent anything to SMDS, morphologically you count the blast percentage if they are more than 20% or not.
Okay.
Then you will say this is acute leukemia or not. But all the suspicious blood pins or peripheral blood they go to flowcytometry.
Yeah.
They tell you which which population is sitting there. Is it myoid or employ? And then you have to decide the genetics on it.
But if for example, this is npm1, you do not need 20%. If even if it is 5%, still it is AML as per WH 2022.
Yeah. If it was separ, then you need uh 20%. We have another young lady which has presented to us again with leading. This is for Okay. [Music] This is more than 19 year old female with white cell count of 62, hemoglobin 100 and it start 140. And go to a sorry the One point. It looks lymphoid. So this blood pin was made by first year biomedical scientist and she said that patient is 19 year old college student. These cells. There's a lot of a lot of um skeleton.
Yeah.
And this is reactive.
Indeed. Uh, it's could be infectious mucosis.
And she gave it to her biomedical scientist consultant, which is M. Yeah.
You have seen so many.
S. [Music] You want the BMS consultant. You can come in.
Well, there's a lot of scalloping around the uh around the red cells. Usually suggest it's infective. Um, there's no uh granulation. There's quite basilic cytoplasm as well on the periphery. I definitely do a um uh a morning spot test.
Mhm.
Um, that would be my first first thing I would do. I mean, the reds look okay. It's just uh I think they say just atypical mononucleiosis because they can often look a lot worse than the cells can look absolutely awful and can be a bit misleading sometimes. But there's nuclear light quite prominent in that one there. Okay. Yes. Looks so serious.
Then you kept it in the tray for clinical take their opinion.
But sorry, but this looks like monol. [Music]
You are clinically. What was the what was the white blood cell count? This is 52,000. White cell count is 62 and the.
Okay.
And the plated count is 110 and the white cell count, sorry, hemoglobin is 100. Biomedical scientists have seen the blood thin and.
Definitely.
Yes. They have kept it in your tray because the first year biomedical scientist thinks that this is infectious mononucleiosis. The consultant has seen many nucleated cells with nuclei. He wants a second opinion from you guys. This patient, this blood frame is in front of you. Now, how would you report it? Oisha is the second one on the list. Russia is not on the left. Okay. Um, WBC shows um total luccoytosis with the increased number of reactive lymphocytes. Um, there are blasts um um I'm not sure about the percentage, but uh they look like um monolast. Then I will describe them like um um immature uh um a increased ancytolasmic ratio with um abundant cytoplasm. um gray blue, a granular, immature chromatin with the I I'm not appreciating like um what about uh RBC's? Can you please put the.
Yeah, there are blocks along with react active lymphocytes. It may be um in both leukemia and infection. But uh regarding why uh RBC's um um normic normocchromic. There are um ano bilocytosis in the form of uh normic normocchromic, some microtes, occasional teardrop cells. Platelets it looks like normal. Uh, what was the count?
110. Mild fromia. Um, I will advise to send the uh uh the peripheral blood sample for flowcytometry and u also to check for viral infection.
Why you think it is viral infection? I I saw along with this BLOS. I I I I've I've I've seen some uh reactive lymphocytes.
Mhm.
No, not all uh scalping um means infection. There are some bluffs with the scalp.
Scalp. All right. No. So a a patient with infections will present with bleeding. This patient is bleeding.
Yeah. This is um emphasize my finding. I think.
And these two cells, they are sticking to one another.
Yes. Yes. I I see the Yeah. Yeah. I I always see this feature with abnormal loss with abnormal cells loss cells.
This is power 10. Um.
Mhm.
Have you seen such picture in infectious videos like no, it is leukemia case suggestive of leukemia for flow psychometry. So if a patient is bleeding, there is anemia, thromosipmia, and a white cell count is 62, then I would not be thinking about infection, mononucle infection mononucleiosis. The count can be 12, can be 13, can be maximum 20, but it would not cause bleeding. The cells would not be sticking to one Another.
The nucleoli inside the cells would not be that much and there will be no vacuum in the nucleus cell.
Yeah. So this was an exam case and majority of the people put it as in practice molecules. That's why I'm saying scalloping is not a feature of infectious mononucleosis. This is a misnomer. Whoever created that has uh put the emergency path for two exam candidates at risk. So whenever the cell count is high, they would scul some of them, isn't it? As well.
Yeah. Quite commonation. They have granules as well.
The monucleiosis cells does not contain them.
No. See any vacuum there. Okay. They will not stick to one another and the count is too high and they will not.
Your dead flow on this patient. 34 is positive. 133 is positive. 14 is positive. 16 is positive.
16 and what else? Myoid and what?
64 and 64 is.
The monopetic is monoplastic.
Yes. Dr. Amir. Uh, excuse me. Um, is it not good to mention um screen for viral infection? Uh, however, I know that it is it is the case of leukemia, but why not coexisting infection to search for or it is not uh to be um it is not better to concentrate on infection in presence of leukemia. So the advice will include only flow and direct the clinician uh towards leukemia only.
Which one is important? Leukemia or bonus?
Yeah, I know. But uh um um I usually uh at my work boot the full advice regarding the patient. So in the exam, it is better to concentrate on leukemia only.
If it is if it is infectious nucleiois, for example, in this case, what would you do? Infection does not need any treatment.
Yes. Uh, got it. Yes. Yes. Problem here is leukemia. Patient is bleeding.
You are right. Okay. Yes. Yes. Thank you.
You need to concentrate on a bigger problem. It was definitely a referral. Anyway, I say that.
Yeah, uh, if I have seen such case my workplace, I would send the peripheral blood for flow. Patient is bleeding, so hematologist should examine the patient, take history from the patient.
Bleeding patient with this picture is emergency and she is 19. Yeah, it's the age as well. Sometimes you think this could cause she's in the age group for infectious monucleiosis as well. Through me.
Yeah. So this patient, another patient is also 19, presented to the emergency department because of fever. This is I will go to power 15. Right. Anything come? So there is marked n isoperculosytosis of the RBC's along with that the WBC shows predominant population of neutrfils and few atypical cells or monuclear cells. Platelets seems adequate. Okay.
The uh lymphocytes, these atypical cells um few seems like monuc um monocytes. What was the total white cell count again? 14. Slightly elevated. Then.
This seems more like atypical cells.
Yeah.
Having high NC ratio. Um.
So what about the spleen? Spleen is normal. What did you ask? Um uh.
Sir, I wanted to rule out one of the cells seemed some somewhat like hairy because of that and even like it's giving an impression of CMML. So for that I was asking for stain again. His age is what?
19 years. No hairy cell. No, no.
It no, it doesn't come with the with this age.
I think these cells look more look more like the reactive lymphocytes. It's a pleomorphic population of lymphocytes that have varying cytoplasm, some with granules. And in this case, yes, there is scalloping. But given the age and the relatively normal red blood cell count and platelet counts, I would probably favor reactive lymphosy.
Mhm.
Yeah, I agree. They look more reactive. So I probably reported as this platform has m local cytosis. Um, there's geomorphic population of lymphocytes with varying degrees of cytoplasm, um granules, some with scalloping, um suggesting reactive lymphocytes. Red blood cell count was and the red blood cell morphology is otherwise um normal chromic, normal citic, and the platelet count is adequate. I actually thought I saw a few how jolly bodies, but probably won't come and this blood film is suggestive of reactive lymphocytosis. Um, suggest viral studies, spot test, um, and correlate clinically.
Yeah, I don't like those. There's a problem nuclear there. And they're sticking together as well.
They look reactive. [Music]
Yeah. So what what was the difference between these sense and the previous lecture? The chromatin of nuclei of nuclei and the size, nucleiocytoplasmic ratio, and um what else? The count, the presentation other than morphology, I mean.
Yeah, presentation is different. This patient is having fever only. The other patient more bleed. This patient count is 14, other patient count is 62. This patient has uh different types and sizes of lymphoid cell. I'm calling it as lymphoid because the chro the cytoplasm is clear. Majority of the cytoplasm is bluish. They have scalloping, and the other blood has scalloping as well. We have seen two cases here where they were near to one another like this. But look at the cytolas. It is blue, and I think only one or two cells we have seen where there were um where where there were veules as well. Rest are all a The previous blood pin has almost similar size of blast or cells. Here the cells structure, shape, everything varies. So this one you can call it as reactive one. Okay. You cannot call it this is monopolastic or this is acute leukem leukemia, especially. No, this is not the blue cytoplasm. Yes. Some of them have skeleton as well. But majority of them have no vacuum. There is no uh sticking to one another. In the previous blood, we see we have seen a lot of cells sticking to one another. And this is the feature of blast when they stick to one another, and uh very few of them, very few of them have vacuumed in this blood, but the previous blood print almost all the cells have vacuum, and the patient presentation was different. Patient over there was bleeding, here the patient is not. That's how you are trick in the exam. You think that these cells have scalloping and patient is 19 year old, infections BL or uh even TAL, and these AML they are common in 19 years age as well. Here leukemia at this age is not possible. CLLL at this age is not possible. So you need to um be ready for any type of scenario. When you see them more, then it is easy to recognize. So make your own slide bank, okay, and look at them till your exam day. This is another patient whose blood film was sent to us by GP. The patient is totally asymptomatic. This is the patient routine envelope blood, and the blood film has come to the to our lab. You can see that. Yes, sir. A lot of population can be seen along with some smud cells. What was the total white cell count?
400.
Yeah. Sorry. It seems more like CNN as the history is suggestible. Yeah.
What about this?
Patient has a big spin.
Yes, sir. This is CLL. Mature lymphoid population along with smud cells.
And like the patient was asymptomatic. So that's an incidental finding.
Okay. So I am the first year biomedical scientist. I saw the smudge cells because my consultant told me that smudge cell is a feature of PLL, and if the cells are small and mature, this is a feature of CLL as well. I reported as it as a CN, but then I thought why not to keep it to take a second opinion from someone senior in the lab. So I give it.
But sir, the lymphocytes are not the typical lymphocytes.
Like in CL, they not um they are not the typical CLL lymphocytes. You know, the nucleus is a bit clefted in places.
And even the cytoplasm, it has got um.
It's a bit of blebin as well.
Yeah. And nuclear lifting is also seen. So it can be something else.
Yeah. I'm shifting away from CLL at the moment because I was told that smudge cell is a feature of CLN. So as a first year biomedical scientist, I reported as CNN, then I give it to you guys. You are the senior and more experienced than me, and and the patient is also asymptomatic. This says that these are uh routine animal blood of the patient. We can report it as lymphop proliferative chronic lymphop proliferative disorder for flowcytometry, but the presence of smudge cells doesn't mean CLL, because these are just a fragile cells. It can appear at any of lymphop.
So we'll go for the imenotyping. We'll go for the t- cell panel. Which cell?
Uh, so for CD7 or for carotyping, translocation 14, it can be PTL.
Yeah, I'm going that way. TPLL is sorry.
It can be like the blebing is get um a bit cuz you can get high white cell comes with TPLL, can't you?
Mhm.
Yeah, I'm going down more. That line definitely needs flow.
Which flow you would like to take? Bend or descend? Please also think.
So first of all, five and 23. CD5 and 23.
23 is negative and five is negative.
Five is.
Negative.
5 and 23 negative. Uh, sir, what about CD 10? Negative.
Um, sir, B cell markers 1979 A 20 uh2.
Negative.
Sir, CD3 cytoplasmic CD3 CD7 CD5.
Positive.
Okay. Cytoplasmic um, then I'll go for. So what about CD7 positive? That's positive.
Then it's TPLN, sir. I'll go for carotyping.
144 14.
144. So then it's um PTL. PPL, sorry.
How you will report this blood?
Uh, Sir, I'll say that there is normal. The predominant population is of uh immature uh blast having high NC ratio, with irregular nuclear contour and one to two prominent nuclei, one prominent nuclei. The cytoplasm is basopilic arranular and having blips, whereas the platelets are reduced on the smear and uh, the uh w the RBC count is like normocitic normocchromic. So um uh atyp uh um 70 to 80% population is of atypical cells of should be followed by bone marrow respiration trifine biopsy and imophenotyping, cytogenetics, and kotyping for further evaluation of this case. And as the um uh flow, flow shows positive as the flow is positive for CD3 and CD7.
I don't have flow at this moment.
Okay, sir.
You have only blood film in front of you.
What are you thinking about in this? This is likely.
This is likely to be TPL.
GP does not understand what is TPL, but.
It is acute leukemia. He understand lymphop proliferative disorder.
Okay, sir. Uh, it is a lymphop proliferative disorder.
If you say leukemia, then GP will send the patient to hospital to ED. You have commented on the white cell. You have commented on the platelets and then red cell. We have given your impression that it's an inoperative disorder like the you have mentioned that we will send a flow to the we will send a little blood dot for sedimentary and arrange arrange um bulbopsy for the patient because patient is stable, he can come to outpatient department, you can talk to him about biopsy or examine him first. What treatment you will give?
Sorry, sir, I don't know.
Anyone LM2 followed by LH HSC. If it's indicated, then you will give u if patient is asymptomatic, maybe he will need.
Patient has penary. If the patient has any pluralusion oritis or lympadenopathy, then then you would consider therefore any quick. Otherwise, the guideline says monitoring for asymptomatic uh cases. Do we monitor any microbiology during uh in TPL like ATL is associated with fungalis, TPLN and TPNLN, what do we monitor? So 17p gene mutation is quite common in it. It's an aggressive one.
Mhm.
Now I'm asking about microbiology.
Did you monitor anything in.
This uh urine treatment, fungal infection? CM monitoring.
HTLV.
HTLV for HLL. [Music] And the CMV monitoring um, they are in the they are in the TPL.
Again, sorry, Dr. CMV monitoring is common during the TPRL treatment. [Music] CMV.
Can you hear me?
Yeah.
Oh, yes. Yes. This is the last game and then we will go somewhere. All right. This is another patient, but this time it is 60 year old, and this is a GP blood thin again, and the void cell count is high as you can see. Hemoglobin is stable. Platelet count is slightly Hello, 130. And this is the blood fil in front of Definitely bluff. How old is the patient?
Patient is 60.
Okay. Very prominent single nucleide. You want two projections maybe as well. Some are posting in the team's messaging, but I cannot see it. All right. What do you think? I will go to the thick side. This is a thinking maybe hairy cell, but no. This could be splenic villainous maybe.
Or prolymphosetics.
There's quite a few hairy projections on these now. And you're in a thick film film.
It's on a thick side.
Yeah.
A few more projections now. Is it here? Hairy cells should have pertinent opinion.
Yeah, it's not doesn't quite look quite hairy cell. It's a very prominent nuclei though.
What type of hair cell?
Yeah. Yeah. Yeah. Um, think about obsolete here is no because we are not using any anymore. The here is a leukemia variant. It is gone now. Yeah, that was my initial thought.
Mhm.
You have seen both the sides, thick side and thin side. What was the difference between thick and thin side?
Well, you get the thick side, you'll see more prominent white blast there, especially if they're like hairy cells.
Mhm.
All right. So what it can be.
I probably say this a bloody.
So this cytosis predominant um medium sized abnormal mature lympoid cells with prominent nucleoline. Um, red blood cells are otherwise I think they look hypocchromic.
Yes, the red cells are hypochromic.
And um, I think some of them are microitic as well. So and then platelet count is adequate. So my impression is that of chronic LPD morphologically suggestive of spinic bell lymphoma leukemia with prominent nuclei. Um, I would suggest to send peripheral blood flow imoponotyping and as well as hemotenics given that the red cells look um microited hypocchromate such as an iron panel.
So almost every cell in this picture shows a permanent nuclei. They are large cells on the peri, but they are small cells on the thick side. We can see more compact chromatin on the thick side. So and on the thick side, they have projections more prominate projection as well than the thin side, giving a look of hair cell, but we know that in hair leukemia may vary. The count is high, but as per WHO 2022, it has been removed now. It has been replaced by.
Clinic predominant nuclei. Yeah, SLLPN predominant nuclear. This is a case of SLLPN where there are a lot of prolymphocytes are present. One of the colleague mentioned prolific BPLL. It has been removed as per W 20.2 to now BPL plus leukemia variant. They are now unified in the form of um SLL PN. I have only seen one case of SL in up till now and I have kept the patient. All of them have prominent material. All right, it's uh any.