Transcription
Hello everyone. Can you hear me? Hello. Can you hear me? Yes, we can.
This is the first case and this is an 80-year-old female with anemia. Don't spending any since many months. Vel count and the pickax are normal. This is power 10. No power 50. Anyone who can come in on the blood or report the blood. Aisha is the first on the list. Can you hear me? Um, Godwin. Yeah. Yeah. This is an 80-year-old lady with persistent anemia since human with normal plated count and normal white cell count. Okay. So the blood. Okay. Sorry. You saying something? No. If you can report the blood film, please.
Okay. So this is a blood film showing um anisocytosis. Um they are microcytes. They are microcytes although I've not seen lymphocytes to compare but looking at the sizes, they are different sizes. Um they're also different shapes. I could see some fragmented red cells. Um there are some echinocytes. Yeah. And then the white cells appear a bit reduced on film. I haven't seen enough white cells on this film. And the platelets, platelets, platelets appear liquid on film. Okay. Can I see the white, the lymphocytes or neutrophils so as to help with my diagnosis? This is an in-vitro comparison. Okay. Okay. So I can see one of the lymphocytes, they look clipped, clipped in sites. [Music]
So what is your impression? You have reported on the cell lines. What is your impression now? Okay. The history again, please. I mean, if it could help because I haven't seen anything. Yeah. So this is an 80-year-old female patient with persistent anemia since a few months with normal white cell count and platelet count. Okay. So I can see pencil cells there and there are some fragments. Uh um the neutrophil doesn't really look dysplastic because with the age and the history, I'll be thinking of possibly an MDS. What neut looks okay? Looks okay. So that's what I'm saying. It's only the anemia. Yeah, I mean, with with the fragmented cells, I mean, I'm thinking of a hemolytic anemia. That's what would be on my mind because for the other cell lines, nothing really stands out to help me clinch the diagnosis. Mhm. Okay. So this is hemolytic anemia. That is correct. So there is polychromasia, there is fragmentation. Patient has anemia as well. So you suspect, your impression is hemolytic anemia. And what is your suggestion to the team because they may contact you later on. This patient has persistent anemia. What should we do? Yeah, they will have, they will have the same thing in their mind. Maybe is this MDS or something else? So when you report the blood film in the exam, you will write comments on the cell lines, your impression, and then your suggestion as well. Okay, this can be or this can be a film from the ward or from emergency. Okay. So if I'm thinking of, first of all, I would need to do uh the hemolytic screen. So they need to check LDH, reticulocyte, and they could also need to check um the direct antiglobulin test and then um the hemolysis as well could also be due to infection, although this has been longstanding. So they could also check for C-reactive protein and also based on the history, if infection is uh it's likely, um as this is since there's anemia, I mean, first, we could also want to exclude hematinic deficiency, I mean, just for completion, um iron, B12, folate. Um yeah, I think based on the results, the um the investigation results that would inform the next um the next test that will be done. Yeah. All right. That test is negative. B12 folate is normal. Infection is negative. What are the differential diagnoses other than these? Okay. So for this patient, if that is negative and all of that, because of the fragmented cells I'm seeing, uh, also the age, could it be? So patient has other causes of hemolysis? Think microangiopathic hemolytic anemia, like can patient have um metallic heart valve? Could possibly be causing hemolysis of the red cells? That's what I'll be thinking. No patient has um any valvular heart disease? Yes, you're correct. This patient has a metallic heart and it has become dysfunctional, which is leading to isolated anemia in the patient. Okay. In an elderly patient, if there is anemia, always keep um metallic heart valve or mechanical hemolysis in your differential. If they say the renal function is okay, liver function, liver function may be slightly abnormal in hemolysis, and that test is negative. Better folate is normal. Patient is not infectious, then yes, then the only suspicion is that this patient may have a clinical. Okay, this patient has mechanical hemolysis because of which the patient has isolated hemolytic non-immune. All right. Okay. If you're appearing in FRC scenario. Okay. All right.
So this is a 56-year-old man with large excoriated patches on the on both the elbows and on the upper back. The GP had prescribed some cream and anti-allergics, but the patient is not responding to antihistamines. The blood test shows hemoglobin of 110, white cell count of 16, and platelet count of 180. This is the blood film because the white cell count was high and is slightly low. The biomedical scientist can make the blood for you. This is power 10. A general overview. And now I will go to Oh, All right. Anyone who can start reporting the blood then? The Lord 100 power. Sah Ali is next on the list. Hello. Hi. Yeah, if you can please report this blood for us. Yeah, I think there is abnormal infiltration with atypical lymphocytes which they are medium to large in size with the high NC ratio, columnar chromatin. I thought the earlier one, it looked like there is some, the nucleus looks like. Mhm. With mature neutrophils, normal or slightly increased platelet count. Okay. We need a report from you. Yeah. So, uh, there is the, in there is leukocytosis mainly lymphocytes, atypical lymphocytes with mature cytoplasm, medium to large size with mature nucleus, medium to large size, karyomorphic nuclei, normal platelet count, and remarkable red cell morphology. The film is suggestive of a lymphoproliferative disorder, and I would like to correlate with flow cytometry. You would suggest flow cytometry in this case? Uh, yes. What type of LPD are you suspecting? B or T? T cell. T cell. Okay. What would you do to find out the clonality in this patient? Uh, usually we'll do, uh, TCR gene rearrangement for alpha beta or gamma delta. Okay. What is your suspicion that what it can be? Uh, given the history of eczema, I'm thinking about the Sezary syndrome. Okay. Yeah. All right. This patient has a refractory eczema not responding to the anti-allergics or antihistamines, and few of the cells that we have seen have deformed nuclei. So this is hinting towards the type of LPD, Sezary syndrome. How do you treat it? Uh, I think usually we will give, uh, chemotherapy. Mhm. And and consolidation with autologous stem cell transplant. Anything else? Is there any photo? Okay. Yeah, I think yes, they usually receive photophoresis. Yeah, they receive photophoresis from NHS DT, and for refractive cases, um, we are discussing MDT for possible drug. Is there any specific immunophenotype markers for, uh, Sezary syndrome? I think it's usually, uh, CD4 positive, but none is specific. It will be, uh, CD2, CD3, and also CD5 positive, and, uh, CD7 negative, and, uh, usually CD4 positive, CD8 negative. So I'm trying to find out an ID and Sezary cells for you guys, but earlier we have seen one. Yeah. Um, but there are not usually so many means cerebellum like brain, cerebellum or cerebrum. This brain has two or three that is typical of, um, cerebrum, brain, cerebrum, but no, they are not. Maybe this one. If they have given you full blood count result in the exam scenario with high count, first of all, always check it at power four. Okay. And if it contains any travel history, the scenario contains any travel history, then checking at power four is a must. There may be a parasite somewhere in the exam. Eosinophilia, high eosinophil count means, um, either this patient has some parasite somewhere hidden, or this patient has Sezary syndrome. The scenario may not be as straightforward like I give you that this patient has refractory, um, eczema. They may tell you that this patient has abnormal full blood count is high. So always look at power four first to see if there is any parasite or not. Normally in a blood film, there are a lot of parasites. You cannot miss it. But in an exam setting, there is only one parasite in the whole blood film. So you need to check it carefully. Uh, when whenever there is a high eosinophil count in the full blood count, and if you fail to find any, any parasite, then go for, um, finding a Sezary cell. They are more likely like this one with a lot of holes and curves in their nuclear material. All right.
This is another 60-year-old patient with progressive anemia. The scenario in the exam is very small. They are very small scenarios, and you will feel that all the scenarios look the same. This is for power 10. And make this power 50. Anyone who can comment on this blood or report the blood. You're next on the list. Yes. Um, so, um, there is, um, red cell anisocytosis with multiple, with polychromasia, occasionally there are spherocytes and multiple cytocytes seen. Mhm. Also, there is, um, platelet looks reduced in number. Neutrophils, um, looks reactive with occasionally, um, lifted as well. This nucleated red cell. So I should add a, a further piece of information. This patient has a background of breast cancer. Yeah. Um, so, um, in the context of breast cancer, so there is evidence of hemolysis with multiple cytocytes and low platelets, which, um, is in keeping with microangiopathic anemia. So if a patient has active cancer or on treatment, it could be cancer-associated MAHA. However, we need just to, um, check Adam 13 to confirm, which is, which. White cell counts are normal. They are not low. They are not, that doesn't look low. Maybe in some. Okay. Sure. Usually with, um, cancer treated MAHA, we treat the underlying cause rather than treating MAHA. Yes. So the blood film contains a lot of and isopropate to the cytosis detail like some polychromatic cells, some fragments, uh, teardrop cells, NRBC, there are myocytes here as well. Yeah. And few of the neutrophils were dysplastic as well. What would you call this? Um, I think leukodystrophy. [Music] Is it a leuko or plastic picture? It could be leuko or plastic picture. We saw the teardrops and the left shifted and nucleated red cells as well. Yeah. So yeah, maybe the, uh, breast cancer is infiltrating the bone marrow now. That's why we have teardrops, we have NRBC, and we have my as well. We have leukodystrophy. Yeah. What are the different causes of leukodystrophic picture? Um, leukodystrophic picture, it could be with severe infection, it could be with bone marrow stress, it could be with myelofibrosis as well. Okay. And bone marrow infiltration by solid malignancy. Yeah. All right. Remember the differentials of leukodystrophic picture, they usually appear in exam. [Music]
This is another patient, 60-year-old with anemia. Today, all the things are related to anemia. This is for And this is I. Anyone with any thoughts about this lecture? Sorry. No. What happened today? All the people are silent. Alashi. Yeah. Um, okay. So there's anemia with, um, anisocytosis, multiple, um, teardrops, poikilocytes, and target cells, and red cell fragments, thrombocytopenia. Mhm. Um, I haven't seen platelet clumps. Neutrophils appear morphologically normal, normal granulation and nuclear lobulation. Um, so I think any, um, anemia with, um, significant anisocytosis, as I said, teardrops and thrombocytopenia, I think that picture is suggestive of, um, um, probably myelofibrosis, although I haven't seen any mature, um, sites. Is there any other features in the red or not? Um, there is a polychromasia. Um, I think it's some stereotypes. Is there any hypochromia in these red? So there's dual population of cells, I think. Yeah, this is the small hypochromic cells and the, uh, well hemoglobinized, normal-sized cells. Are there any Howell-Jolly bodies? Yeah, I think I saw I saw one Howell-Jolly body and then I, uh, yeah, I can see two now. All right. Those features of hypochromia. Um. Oh. So what, what are you talking about? So, um, so with the target cells, hypochromic microcytic cells, and the Howell-Jolly bodies, these with, um, hypochromia or Um, not sure if this is hemoglobinopathy. I feel like it could be mild fibrosis with marrow abnormality. Okay. So your impression is likely myelofibrosis, and what would you suggest? So I would, um, want to, um, uh, see, I do, I would suggest that I would do further investigations, um, send for, uh, driver mutations, JAK2, CALR, MPL, and PCR, and, um, we do abdominal ultrasound for splenomegaly, and then bone marrow biopsy. Okay. Uh, what is the diagnostic criteria for myelofibrosis? How would you confirm that this is myelo? Sorry for the background noise. Um, so the, um, criteria, there are major and minor criteria. So you have to have at least three major criteria with one of the minors. So bone marrow, um, myeloproliferative proliferation and atypia, and presence of driver mutation, JAK2, CALR, or MPL, and, um, not in keeping with other myeloid malignancies. Uh, the, uh, major, the minor criteria is splenomegaly, thrombocytosis, high white cell count, and high LDH, I think. Okay. So how many major criteria and how many minor criteria should be present to confirm that you have? So three major. So you have to have the characteristic, um, myeloproliferative proliferation and atypia, and, um, one of the driver mutation, and not meeting the other myeloid malignancies, and one of the minors. So leukocytosis or splenomegaly or thrombocytosis. So three major, I think, and one minor, if I'm not wrong. What is the prognostic score for myelo? So there are a few prognostic scoring systems. I think the DIPSS plus, um, there's, um, I think, um, Mick, I think. Can't remember off the top of my head, to be honest, but score is high. What would you offer to this patient? How old is the patient? 60. So I think, um, yeah, if he's, uh, JAK positive with, um, high DIPSS score, then I would offer him, uh, JAK inhibitor, ruxolitinib, or fedratinib. Can you use anything else? If there's evidence of anemia, I think we use, um, fedratinib. Myelofibrosis patients would have anemia all the time. Can you use them first line? I'm not sure. I can't remember off the top of my head. You can use them first line. There's no issue with that. Yeah, I think patients who don't, because if you, you prefer to start fedratinib to give fedratinib rather than ruxolitinib if they have significant anemia. Can you offer them transplant? Yes, if they are high risk. I think if unless unless they, you know, if they, I'll start the, um, JAK2 inhibitor and then I would refer them to a transplant center for, um, assessment. If they are transplant eligible, we start JAK2 inhibitor till the match is available or suitable donor is available, and then they can be transplanted. Okay. Before they progress. Yeah. And if the transplant is not an option or there is no match available, you can use any of the JAK inhibitors according to the new myelofibrosis guideline 2024. It can be fedratinib as a first line. It can be, um, as a first line. Okay. With dose adjustment according to the renal function and platelet count. They have given the table what should be the dose with different platelet counts. Okay. Okay.
This is another case, the last case of the day. Another anemia case. This is a 32-year-old female with progressive fatigue, shortness of breath, and jaundice. She is febrile as well and has a sore throat. Enter. This is power 10. Now we will go to power 50. This is an equal blood. The full blood count hemoglobin is 60, white cell count is 13, and platelet count is 400. Report the blood film and what are the different diagnoses. Sun. Yes, I'm, uh So this is a young lady with symptomatic anemia, upper and lower respiratory tract infection. This is a Nikos blood film. You can see it in your lab. Right. So starting with red cells, there is red cell anisocytosis of different sizes and, um, there is, there are spherocytes, microcytes, hypochromic cells, teardrop, few schistocytes as well. Can see fragments and there is red cell agglutination. Uh, and platelets look increased with mild platelet anisocytosis. We just saw one neutrophil so far, looks okay. Normal granulation and lobulation. And this is fairly okay as well. But there is a vacuolation inside or what's this? Yeah. So reactive. Yeah. This, so toxic changes and vacuolation. Mhm. Is the patient septic, you said? Or Yes, patient has symptomatic anemia with signs of upper and lower respiratory tract infection. Okay. I don't have the clue from, uh, for the neutrophil vacuolation, but, so, so given the spherocytes in the red cells and polychromasia, I would say there are features of hemolysis in the red cell lineage, reactive changes in the white cells, the neutrophil in the neutrophils, toxic changes. So I need to rule out, uh, autoimmune anemia. Okay. So the impression is hemolytic anemia in this. Yeah. Hemolytic in general. Yes. And what investigations will you request? Uh, will do LDH, haptoglobin, B12, folate, iron studies, bilirubin. Uh, DAT test and iron studies for completion. And given the, I need to check infection markers. So CRP and send sputum cultures, blood cultures, and respiratory viral swabs. Which infections are associated with autoimmune anemia? Mycoplasma mainly. So, yeah, plasma antigens and biology. You will send the atypical screen in this patient as well. We have sent for those, T-score and CRP, blood pressure. Oh, perfect. Okay. Yeah. What can be the likely cause of hemolysis in this patient? Uh, likely would be warm autoimmune hemolytic anemia. So I will correlate with that test. Secondary to Mycoplasma pneumoniae infection. Just say infection because we don't know what can be the source of infection, but this patient has symptoms of upper and lower respiratory tract infection. It can be bacterial, it can be viral, and then they can ask you what are the different causes of autoimmune anemia again, you will say primary and secondary. Secondary causes are infection, autoimmune malignancy, spleen, and birth. How would you treat this patient's anemia? Uh, so mainly supportive transfusion. Uh, as I said earlier today, patient is symptomatic and treat the underlying cause if infection. So treat the infection. So if it is cold agglutinin, it mainly will be supportive treatment and treat the underlying cause. If it is warm autoimmune hemolytic anemia with IgG positive, in that I will start steroids. So just where can benefit starting steroid in active sepsis or active infection. In this patient, if you start steroid, you will feel the patient. Yeah, just because the question was a bit general. So if I stick to the Mycoplasma code, when they give you a scenario in the exam, all the questions will be related to this, related to the scenario, but if they want to ask you a general question, then they will say, um, how would you treat autoimmune anemia generally? But this specific patient, we know that this is most likely secondary to infection. There is no role of steroid. If the patient is symptomatic with anemia, then yes, we can give her give the patient transfusion, folic acid, VTE prophylaxis should be done, and treat the underlying cause. Steroid is for primary when whenever there is a primary autoimmune anemia, then you will give steroid. Otherwise, if you give steroid, this patient's immune system will be suppressed more, and the infection will spread in the body more. If you're giving steroid, we are suppressing the immune system, right? Yeah. And the infection will spread in the body because you have weakened the immune system more by giving steroid. But if it was a primary autoimmune, then yes, my own body is destroying my red cells, then I would suppress my immune system by taking steroids. But whenever there is a cause, you treat the cause. No need of steroid, no need of any other chemotherapy drug. Okay. Okay.
These are common daily life anemia, secondary autoimmune hemolytic anemia, or mechanical hemolysis, or leukodystrophic film, or myelofibrosis, or CML, etc. These are common cases of anemia that we face in our practice, and these are the cases that appear in the exam. In exams, in the FRC part exam, there are not always complex cases. These cases appear. We had iron deficiency anemia. We had B12 deficiency anemia. In the same exam, we have HbSS, straightforward case. We have infectious mononucleosis, straightforward case. Mental, and we have very straightforward cases, just like we see in our daily life. But it is the exam pressure, and the first day of the exam, and just nine minutes for each slide, so things get messed up. So, um, if you are working here in the UK, so you must go to your lab and see all the Nikos slides. The lab scientist may have the Nikos folder or drawer in their lab. See them and ask for Nikos login. They may ask you to make your own by using their lab passwords, or they may give you the access to the folder where they would have set up the PDF files of all the Nikos slides. There's a number like 2207B, this is the number of this Nikos slide. Okay. So when you write it in the folder, the answer will appear with detailed explanation by Abra or someone else. And, um, um, still you have a month or month and a half, you will paste two more Nikos, um, slides before the exam. Try to report them. The quality of the slides in the exam is just like these slides. These are Nikos slides. You will see all the cells like this. So once your eyes are addicted to Nikos slides, there will be no difficulty because when we change slides from lab to lab, the quality is different, and the appearance of the slides and blood cells are different. So from now on, start seeing a lot of Nikos slides so that you are okay to them and do not change your microscope. Stick to one microscope. This is the advice I can give you from for the exam from morphology. Thank you very much. If you have any questions, you can ask now. No questions, then enjoy your day. Take care everyone. Bye.