Transcription
e, hello. Can you hear me? Can you hear me okay? So, we will start with our first case. This is a 50-year-old male patient who was referred to hematology because of progressive anemia and tiredness. The full blood count was done and it shows HP of 98, normal white cell count, and slightly low PL. This is the power 10.
e. So, this is the power 10 overview. And now let's go to Power 50.
e. Right, so you have seen the section. You are asked to report this blood film. How would you report this blood film?
Yes, yes. Go. Uh, prefer blood film shows anisocytosis with poikilocytosis, uh, schistocytes and Howell-Jolly bodies and some target cells and these tear drop cells. Right. So, this is not the complete report. You have to complete your report.
Complete. Platelets look uh adequate and white blood cells also uh look normal and adequate number. No increase, no increase in white blood cells. These things. Howell-Jolly bodies, I already mentioned. Okay. Hypochromic cells, hypochromic cells are evident. Hypo. Still, your report is not complete. You need to give your impression.
There is a lot of tear dropping that you have noticed. There are Howell-Jolly bodies. There. There were two target cells. Uh, there were, there is hypochromia as well. White cells have no abnormality. There are rare polychromatic cells as well. L and anisocytosis because two platelets are small, few are large. Patient is anemic. What do you think can be the likely possibility here?
So, this patient has Howell-Jolly bodies. What does it signify? Hyperism? Hyper or hypo? H. Hyposplenism, sorry. Patient is 56 years old. He has developed hyposplenism and he has anemia as well. What will be your differentials in your mind if someone has hyposplenism and anemia at the age of 50?
So, let's say I, I tell you this patient has abdominal discomfort because of the um splenomegaly. Now, this patient has anemia, splenomegaly, and this is the blood film in in front of you. The features, tear drops. We will suspect myelofibrosis. Okay. So, in general, for the exam purpose and also for real life as well, if someone asks you that this patient is progressively anemic and he has splenomegaly as well, so I would think about two differentials on the top. Either this patient has myelofibrosis or he has hairy cell leukemia. I need a blood film for this to see what is the picture over there. If he has hairy tear drops, so likely myelofibrosis. I cannot diagnose myelofibrosis on blood film. It has a specific criteria. Um, and if there are hairy, yes, like it is hairy cell leukemia, still I have to confirm it on bone marrow biopsy and hairy cell leukemia immunophenotype.
Yeah, so you think that this is uh myelofibrosis. This patient has done bone marrow biopsy because everyone was thinking that this may be uh myelofibrosis. So, let's see what does the fine says that this is power four. For the fine. Hope it is clear to you. This, this is H and E stain. Um, although we use a lot of stains in our HMDs diagnostic services, but for the exam, it is H and E that will appear. Giemsa stain will also will only come for the stomach muscle cytosis because muscle cells like Giemsa stain. Do you have any comment on this power four?
Length of trabeculae is fine. Trabecular spaces are okay as well. The trabeculae are a bit distorted. They are fragmented and thickened as well. And you can see these linings here. This one, this one, and one. The feature of fibrosis in in this patient here as well. These megakaryocytes are small. They are not small because they are a feature of myelofibrosis. They are small because they are squeezed between the fibers. Small mega is a feature of CML and MDS 5q only. Rest of the conditions as normal mega. So, still, if you cannot pick it up on on this one, they will give you reticulin. So, this is your reticulin. And I will make it for 10. And you can see these fibers intermingling. So, this is either grade three or grade four fibrosis in the patient. Make it more big. You. This is. You can see is all fibers intermingling. These are all inter. So, this patient has um myelofibrosis. This is grade three. This patient has um mega. Grade ATP as well. You have noticed small mega in this one because they were contracted by the um um nearby fiber. And you have to exclude BCR-ABL1 according to the WHO 2022 criteria. Then you should have minor criteria as well. If I LH, blasttic picture, SP, white cell count high, then it will make a diagnosis of MPN. So, when you report the blood film for the FC exam purpose, you need to comment on the cell line, um, starting from the one which has the abnormality, and then you have to give your impression, like whether this is what are you suspecting in this patient, and then you have to give your opinion as well, suggestion, what, what next you would like to do in this patient. This patient has a lot of red cell features which you have mentioned, and the L, anisocytosis. White cell count was normal. White cell, white cell morphology was normal. Impression is likely of myelofibrosis. We would like to do a bone marrow biopsy in this patient and BCR-ABL1 to to exclude the diagnosis of myelofibrosis or other myeloproliferative disorders. Then your complete will be your report will be complete for the exam purpose. Obviously, uh, you belong to different countries. There is different, different reporting system, but for UK, they give first comment on the cells, then your impression, and then your suggestion, because most of the blood films, they will be sent to you by the GP, and not they are not in the hospital. You will comment on the blood film, and they will expect you what, what we are thinking and what they should do next.
The next case is a 19-year-old uh male who was referred to us because of progressive anemia and tiredness. This is power 10.
e. Okay, so let's see this film on how what. So, hemoglobin in this patient is 110. White cell count is 22, and platelet count is 130. And obviously, it is visible from power 10. Micro. Yeah, there is some problem with white cells in this patient. So, let's go to power 50 and see what is.
So, your lab colleague has seen the blood film and he thinks that this is um CLL. But the other colleague in the lab has seen this blood film and he, he thinks that the patient is young, 19 years old. So, these are reactive lymphocytes. Now, they have sent the blood film to you for your reporting and comment. Let's see few slides here, and then you can comment on the back. What do you think?
Definitely, this is not uh CLL, nor it is a reactive lymphocyte. You have to then report the blood film. Yeah, and teach your lab staff that what are you thinking about this.
Good afternoon. Anyone? Do you hear me? Yes, we can hear you. Uh, I noticed that there is mild anisocytosis, there is leukocytosis, mild lymphocytosis with a little bit small lymphocytes with fine chromatin, high N:C ratio, and marked thrombocytopenia.
Okay. So, what is your impression? My impression may be acute leukemia for immunotyping to confirm the diagnosis.
Okay. So, you would like to send peripheral blood for immunophenotyping. And this peripheral blood for immunophenotyping. Okay. CD19 is positive. CD10 is positive. CD20 is positive. CD4 is negative. CD5 is negative. CD7 is negative. TdT is positive as well. What about surface immunoglobulin? The surface immunoglobulin is negative. But we, I should say, we, it is, we 379A. What about it? CD79 is negative. I'm not sure, but maybe leukemia according to morphology. Maybe L1. We do not use the FAB classification anymore.
Okay. So, first of all, tell us about these cells. What makes you think that this is acute leukemia and it is not CLL or infectious mononucleosis? Be quick, guys. I have to. My N:C ratio is a relatively open chromatin, and there is some nuclei as well, and they are monomorphic. They're not polymorphic like the L1s. Very scanty cytoplasm. Yeah, there is obvious. Make it power 100 if I can. So, this is the present in this cell, and this one as well. This has a lot of nuclei, and this one has many as well. Cytoplasm is very scanty. So, on the peripheral blood, we can only say that this is leukemia or not. This patient has is uh likely acute leukemia. And give your suggestion that we need urgent peripheral blood flow cytometry for this patient. When I mentioned to you the TdT, TdT is a marker of immaturity. It means, um, this is acute leukemia. But on peripheral blood, you cannot say whether this is acute myeloid leukemia or acute lymphoblastic leukemia. You need a peripheral blood flow for that, because things usually are deceiving on the peripheral blood film morphology. On, you may be thinking acute myeloid, it comes out as ALL. You may be thinking ALL, it comes out as AML. We always trust on the uh flow cytometry.
Okay. Can you tell me any standard risk cytogenetics or unfavorable risk cytogenetics in ALL? Good and genetic and genetic. So, high patients, um, the age, um, and the high. I'm asking about cytogenetics. One standard is cytogenetics and one unfavorable is cytogenetics. Right. So, the standard, um, basically not high risk. The high risk is Philadelphia BCR-ABL1, um, t(11;19). Mhm. And ML. What about the standard? Standard genetics. Um, I'm not sure. I think hyperdiploidy, but I'm not sure. What other? Sorry. Yes, hyperdiploidy carries standard risk. Cytogenetics everywhere. And hypodiploidy carries two risk. Cytogenetics. 12;21 translocation is a standard translocation in, okay, in the ALL.
Okay. So, this is another case. Third case. And this is a again, 19-year-old boy with anemia. He is an immigrant from, uh, somewhere to UK, and the GP referred this patient to you because the patient had abdominal discomfort and low hemoglobin as well. The parents told you that we were, he was diagnosed as a sickle cell patient back in the country. So, this is the power 10. And let's go to power 15 for more detail.
e. Can I come in? Good. RBCs show anisocytosis including target cells, sickle cells, poikilocytosis, Howell-Jolly bodies. Um, there are some microcytic hypochromic cells also. I didn't recognize the white blood cell morphology. Can you? The patient presented with what? Anemia. Oh, so well, now the [Music] why? What are these? Oh, M block or what? No, no. Activated monocytes. Can you move again for more detail? Activated reactive lymphocytes. LFTs are how, how much? Or 130? Sorry, 160. If you, if you can comment on the white cell, that is fine. If not, it is not an issue. Yeah, I think activated and reactive lymphocytes. This patient has a dual diagnosis. So, I brought it only for the purpose of hemoglobinopathy. But would target. It means something. Hemoglobin maybe. Okay. So, you want HPLC from me? So, um, the sickle cell is 78%. A2 is 7%. A, not is 5%. Sickle. Okay. A2 is what? A2? 7%. Oh, can you tell your colleagues why you are thinking this is sickle cell beta and not homozygous sickle cell? Sickle cell comes with a high A2 level and it comes with the target. In presence of sickle cell, A2 does not carry any value. It is the A not that you have to consider. So, sickle cell because sickle cell is 78% and there is some A in this patient as well, and you would have F percentage in this patient as well. If it was only sickle cell, you would see all the sickle cells here because there is hypochromia, target cells, features, MCV in this patient would be very low. And there is some hemoglobin, some beta chain activity is present. So, this is sickle cell beta hemoglobin above five, five or above five means beta plus. If the hemoglobin was 2%, A not was 2% or 3%, I would have called it as sickle cell beta not. Sorry, can you repeat that again, Dr. Am? So, because this, if this patient has all the sickle cells on the blood film and the HPLC says that sickle percentage is 90%, sickle hemoglobin is 90%, so this is homozygous sickle cell. If, if the, in this patient, the sickle hemoglobin percentage is 7, 78%, there is some F in this patient as well, and hemoglobin A not is 5%. It means there are some beta cell chain, beta chain activity present in this patient. He is not completely homozygous sickle cell because of beta chain activity, you are seeing microcytosis in this patient, some target cells in this patient, hypochromia, because activity is very less, but still there. So, when you report on the HPLC, you look at the abnormal hemoglobin which is sickle cell here. What is A2? What is A not? What is the F percentage? To compensate for high sickle cell, hemoglobin, this patient would have some, uh, F percentage as well. If it is all sickle hemoglobin, it becomes homozygous sickle cell. If it is 70 to 80% hemoglobin, sickle hemoglobin, and you have some A not, A not is the our hemoglobin, the adult hemoglobin, it means there is some beta cell beta chain activity is present. It becomes sickle cell beta. Then you quantify beta. You quantify A not level. If it is above 5% or below 5%. If it is above 5%, it is sickle cell beta plus. If it is below 5%, it is sickle cell beta minus. Is it making sense or not? Yes. Okay. So, A2 does not carry value in presence of sickle cell. It is A not, the adult hemoglobin, which carries value. If you don't have A not, and it's only sickle hemoglobin, then it is HS. If you have some A not, then you need to quantify it. How much A not is there? Above 5% or below 5%. Above 5% beta plus, below 5% beta minus. And I mentioned this patient has dual diagnosis. These are two big. This one I mentioned this patient has dual diagnosis. That's why I was not commenting on the white cell. Usually, such films does not come in the exam with the dual diagnosis. This patient has ALL plus beta. And regarding the reactive lymphocytes, reactive lymphocytes usually have scalloping. These cells don't have scalloping. They are blast-like. Some of the white cells have nuclei and they have minimal cytoplasm. So, only I commented on the red cell pathology, not on the white cell, because dual pathologies usually does not come in the exam. You may have seen your patients who may have multiple myeloma plus CL phenotype as well, who may have biotypic leukemia, who may have CML and ALL phenotype at the same time, but in the exam, they does not appear. If it was reactive lymphocyte, they would, they would have a lot of cytoplasm and it would have scalloped these cells. And these cells, I had shown you the infectious mononucleosis cells before. It enveloped the cells and they are quite large cells. These are small cells. They have minimal cytoplasm. They are leukemic cells. But I did not, I was not touching these because it is a dual diagnostic, dual diagnosis makes you confused in the exam. That's why it does not appear.
This is again a 19-year-old young patient who had a motorcycle accident 3 years ago and has abdominal surgery. This film is not for diagnostic purpose. This film is just for the features. What features do you see in this blood film? Abnormal features do you see in this blood film? This is power 10. And regarding HPLC, HPLC is a part two question. It will not appear in part one. You will have HPLC graph with you. You can quantify the hemoglobin very easily. Now let's go to power.
So, what abnormality do you see in this blood film? And does it correlate with the patient's abdominal surgery or not?
Red blood cells and anisocytosis with the marked um target cells, spherocytes, and see how really is which does correlate with possible splenectomy. What are other features of? You mentioned Howell-Jolly bodies, target cells. Is there any other feature of connection? Reactive thrombocytosis is a feature of splenectomy. So, when you go through the ET guideline and you open the table in the BS guidelines for essential thrombocythemia, they tell you one of the reactive cause of thrombocytosis is splenectomy. Some of the blood films in the part exam will be for listing the features in the blood film. They will ask you, list six features in this blood film. You will write target cell, Howell-Jolly body, one RBC, nucleated RBC. We have seen, if there is splenectomy, we have seen microcytosis. Thrombocytosis. All the blood films in the exam are not for reporting purpose, are not for diagnostic purpose. They may ask you, what is the differential diagnosis of? Yeah, so this blood film is uh post-splenectomy. People think that this may be hemoglobinopathy because of the lot of target cells. No, this is not a hemoglobinopathy because previously he is well. He was well. No family history of any hemoglobinopathy. Abdominal surgery. This patient has had abdominal surgery because of splenectomy and splenectomy. That's why we are seeing a lot of Howell-Jolly bodies in this blood film. Thrombocytosis, target cells. So, the next question can be, um, what prophylaxis would you suggest? Any prophylaxis for this patient or not? Vaccination. Vaccination and influenza vaccine. Yes. You can say in terms of encapsulated bacteria organism. I think there was a recent update regarding the Haemophilus influenza. They have removed Haemophilus influenza from the, uh, regular vaccination. It's only meningococcal and pneumococcal vaccination. Check that in the guideline. And what else? Penicillin and folic acid. Penicillin and folic acid as well. Right. Because of splenectomy, they are at risk of two major things. One is infection. And what is the another risk factor in a patient with splenectomy? I think maybe thrombosis. Thrombocytosis. Your first point was correct. We are at risk of thrombosis, especially venous thrombosis. Which venous thrombosis? All the veins are deep inside our body, but there is a specific vein which is more prone to have thrombus, and it is usually part one MCQ question as well. Hepatic vein thrombosis. Portal vein thrombosis. Portal. I'm working in the lab for many years. For good money, many information. Sorry. So, they appear as effusions. They ask which post. And we usually do not give them prophylactic thrombosis, like prophylaxis. We do not give these patients. But if they have any other risk factors, for example, they are obese, or they have any cancer as well, or having any active chemotherapy, and we think that they are at risk of having clot, then we give them prophylaxis. It is always case-by-case situation. Routinely, we do not give anticoagulation.
This is the last case that was posted in the group as well. Uh, sorry, may I ask for the previous film? Yes. Yeah, just with the target cells, because we're really significant, is that actually one of the main features of splenectomy? Increases target cells. Yeah. So, target cells can appear in many conditions like in hemoglobinopathies, liver disease, and splenectomy as well. So, this patient, liver was normal. He had no previous history of any hemoglobinopathy. Yeah, he had splenectomy. So, in UK, you keep the record of everything. If you go to your hospital and ask for your blood test from 2001, they will have the blood test records and blood films as well. So, this patient had no previous such findings on the peripheral blood film. They appear post. So, liver, target cells can appear in liver disease and hemoglobinopathies and splenectomy. Sure. Okay. The patient has no spleen at all. Yes. He developed target cells, thrombosis, and Howell-Jolly bodies. Right. Okay. Yeah, thank you.
This is the last case. This is a 5-year-old boy with. This is power 10. Sorry, did you say with jaundice? Jaundice. Yeah. This is power 50. You will see this film in your exam if you're going for C. This is from E. This is not a red cell picture. One of the, someone mentioned that this is a red cell picture. This is not. What are the findings in this? Yeah, there is a red cell anisocytosis with, um, there are, it's kind of mixed population, really. There are spherocytes, microspherocytes, polychromasia, and many hypochromic, um, cells as well. There are many elliptocyte-like cells, and, uh, tear, occasional teardrop-like cells. Okay. Yeah, features are going with, um, likely hemolysis. Yes, hemolytic anemia. But what? Right. So, I would like to do further investigation to exclude, um, intravascular hemolysis like cold hemoglobin or hemoglobin. Sorry. P. It's if it was cold, there should be some red cell agglutination. Right. Yeah, yeah, you are right. First step in hemolysis is always a DAT test to find out whether whether it is immune or non-immune. Yeah, yeah. So, that test is negative here. Okay. So, like non-immune hemolytic anemia, what do you think? Pies looks like that. Congenital dyserythropoietic anemia. CDA. Yes. Yes. Usually, we diagnose that on the aspirate, not on the peripheral blood. And congenital dyserythropoietic anemia has other systemic features as well, and peripheral blood film is not that severe. This blood film has macrocytosis, hypochromia, spherocytes. Even, sorry, what did you? Maybe membrane RBCs membrane defect. Yes. RBC membrane defects are, uh, more than five as far as I know. Which RBC membrane defect? Stomatocytosis. Spherocytosis. Sorry. There is spherocytosis. There is ovalocytosis. This is spherocytosis or ovalocytosis? The ovalocyte is more prominent. Yeah. Ovalocytes are prominent here. But somebody says this is ovalocytosis. Maybe this is elliptocytosis or stomatocytosis. What is this? This is not stomatocytosis. I, ectocytosis. You say this is ellipto. What about these? Theoy. Think about these theoy. There are so [Music] many. Maybe transfused. If they were transfused, there should be a lot of cells like this one. Yeah, but there are only few cells like this. Transfused should not have this much of spherocytes. This slide is full of spherocytosis. Then what about these? Elliptocytes. This is poikilocytosis. You can, you can see a wide range of anisocytosis and poikilocytosis in this blood film. This film has macrocytes, elliptocytes, spherocytes, fragments, teardrop cells, Howell-Jolly bodies, contracted cells. Everything. Medical terminology. The lab terminology is vomitus of, uh, red cell or red cell vomitus. So, this is herio. If it was spherocytosis, then then you should have only spherocytes. If it is elliptocytosis, then you should have only elliptocytes. I think I had showed you the ellipto before, which is full of ovalocytes like this. They don't have macrocytes or spherocytes. Teardrop. Is it autosomal recessive or dominant? This one is. And it is usually a mild disorder. Does not need frequent transfusion. Just observation and folic acid. In the, and nothing yet. Okay.
That was it for today. And enjoy the Sunday. Do you have any questions? Thank you. If you are preparing for part two exam, part two exam, and I would advise to join regularly and not join regularly, participate as well. You can participate here. You will be good in the exam because most of the people fail the day one of part two exam because people are having anxiety for the exam. They are going for the first time. The timing is the issue. Nine minutes for one, uh, blood film. It's not that they don't know, but because of the timing issue, they usually fail the questions and fail the exam. Do not hesitate. Nobody knows you. Okay. If you are afraid that some of your friends will know you that this man does not know anything, change your name on the screen. But I would encourage you to participate. It's for your benefit. I'm done with my exam. I'm doing the sessions only for my interest. Thank you. Okay. So, take care and have a nice Sunday. And see you next Sunday then. Thank you very much.