Transcription
Okay, so to start again. The first case: a 19-year-old boy who is an immigrant from Rwanda arrived in the UK two days back. He has a high fever which is intermittent, along with sweating as well. He was sent by GP to the emergency unit. His full blood count shows hemoglobin of 133, PLT count of 110, and the white cell count is eight. This is the blood film of the patient because the BMS mentioned that the depleted count is low and he is junior. If you can review the blood film for him. So, who wants to go first? Any volunteer? Come on, anyone. Exam is on the third of October. Anyone wants to go ahead? This case will come this time because it did not appear in the last exam. The first on the list is Ember Seal. You want to go ahead?
Hi, good morning. Yeah, morning. I can give it a go. Sorry for the background noise. No worries, it's okay.
Okay, so you have heard the story that this is a 19-year-old guy with persistent fevers, and he is an immigrant from Rwanda. The BMS is new, and he has noticed thrombocytopenia, and he wants to have a look at the blood. Yeah, so this is the power 10. Yeah, um, I think from this distance, um, um, I [Music] can. Yeah, I, I think I will show you 50 oil and 100 oil as well, then you can report the blood film in the exam. Okay, so this is 50 oil. Mhm. [Music] Yeah, I think quiet please. Be quiet, Mama. Be quiet. Be quiet. Be quiet. Be quiet. So I can, I think trying to focus it for you. I think this is better. Yeah, I think, um, now report the blood film. How would you report for the exam purpose? Yeah, I think I, I will start systematically, um, mentioning that commenting on the platelets first. Um, um, I couldn't see any, um, platelets, so it will be, um, thrombo, thrombocytopenia. No evidence of clumps. Be quiet. Um, and, uh, RBCs, um, I can see intracellular, um, um, ring forms in within the RBCs. Okay, so how would you describe these ring forms? Mama, quiet. I think I will, um, mention it, um, intracellular, intracellular organisms with, um, malarial parasites. Pardon? Malarial parasites. Malarial parasites. Yeah. The blood, so the blood film contains malarial parasites in the red blood cells. The size of the red blood cells are normal. The rings are thin, some with double dot shape, and some near to the red cell membrane, which are equally formed. We have seen multiple, um, red cells with double rings as well. The crescent form of Plasmodium falciparum is very rare to see in the blood. Yes, you have to comment on the white cell count and detail it as well, whether they are increased, normal, or abnormal, or a decrease. So the film is most likely consistent with, uh, malarial infection, likely Plasmodium falciparum, which needs to be confirmed on further testing like rapid diagnostic test or, and by nested PCR by sending the sample to the [Music] reference lab. This will constitute your report. You have explained your findings, you have given your suspicion, which is Plasmodium falciparum, and you have suggested further testing by RDT and, uh, by referring the sample to, uh, reference lab. So that they can do PCR. Right, now the next question would be, uh, what is the principle of RDT? Rapid diagnostic test. So, rapid diagnostic test is a lateral flow immunochromatographic antigen detection test which detects the antigen of the malarial parasite. Okay. This test uses a dye-labeled antibody which binds to, uh, malarial antigen, and this combination of antigen and the antibody gives you a line in the, in the test. The kit is the same as we use for the COVID test. So the last question would be, uh, how would you manage this patient? I think I will say, um, I think I will say this patient needs, um, urgent medical, um, um, assessment and, um, admission. Um, so if it's a, was it, if it's a, yeah, if it's a GP sample, we patients need to be, uh, urgently admitted to hospital and, um, the patient is in the patient is in the ED, referred to you, referred to ED by the GP. So the patient is in the ED. Okay, so I will say this patient needs urgent medical, uh, assessment and discussion with the infectious disease team, um, and the full set of history on examination and investigations including, um, LFTs and hemolytic markers needs to be done. The patient needs admission either under the medical team or infectious disease team if the hospital has an infectious disease ward, plus confirmation of the infection, uh, by the investigation like RDT or nested PCR, and, um, depending upon the parasite density or the, the type of parasite or the, uh, infection disease team would manage accordingly. Sometimes, in the exam, they ask you the question, what are the indications of, uh, exchange transfusion in malaria patients? Parasitemia more than 10%, and evidence of hemolysis. If there is cerebral malaria, it is an indication of, an exchange transfusion. If the patient is severely ill with multiple organ involvement, or I think the parasitemia is more than 30%, not more than 10%, then usually the infectious disease team will manage whether we can do exchange transfusion for such patients. Or so in the exam, you have to write your diagnosis as either Plasmodium falciparum or non-falciparum. Exam wants a distinction between falciparum and non-falciparum only. They are not interested to say that this is Plasmodium malaria or anything. If you can differentiate between falciparum and non-falciparum, that is enough. And then, uh, the hematology has given a table which differentiates the different species of Plasmodium from one another according to the size, the thickness of the ring, multiple rings in the same cell, and, uh, the rings near to the, uh, red cell membrane, they are called appliqué. There is a specific shape of Plasmodium falciparum gametocyte in the form of crescent or moon shape. Another important question is, uh, RDT principle, then is the indication of red cell exchange in malaria, and third one and the last one is, uh, management is usually managed by artemisinin-based drugs. If you can remember that, that is. I hope they would not ask more than this, and I have never heard that malaria has appeared in the W section. So hopefully, can I ask a question please? When, when we start reporting a blood film or aspirate, do we usually start with the abnormalities first, or do we just have a plan and go systematically? Usually confused with this. Speed start. What is prominent in the blood film? Okay, okay. So any abnormality which is evident in the blood film, start with that. Okay, that's fine. Thank you.
So, this second patient is a 45-year-old boy, um, whose blood sample has been referred to you by GP. The patient is not in the hospital. You have received blood sample from the GP. PP only, and the blood film shows white cell count of 66, hemoglobin of 129, and platelet count of 120. So, anyone who wants to go ahead with this case? Just. So, the next person on the list is D. D, do you want to go ahead with this case?
Sure, sure. No worry. Uh, okay, so this is the power 10, and then I will show you power 50 as well, and then you can report the blood film. Yeah, just from this picture, it seems like that, um, I can tell you. Okay, okay, that's great. One second, give me one second. I can see that. Can you center? Can you make the visualize the center, please? Make it to 50, and then you can see them more clearly. Yeah, this little darker. Yeah, that's better. Okay, stop it, please. Yeah, okay. [Music] Do you want me to go around? Yeah, from the red cell, it looks like there are few spherocytes. I can see in this red blood cell, but the size looks a little smaller cell than the, I can say that. And most of the, you can see there and other, you can see there is a lymphocyte. There are lymphocytes. They are bigger, different size. It looks like some kind of myeloblast or something, but I'm not sure. Okay, the patient, but these look like lymphocytes. Kind of picture. Looks like the nucleus is mature. So they are not. Yeah, yeah, I will go around to show you more cells. Yeah, yeah. Look, few I can see microcytes, few leptocytes, but hypochromic. Can you stop that, please? Okay. NRBC. Left shift. Okay. This is the one in the center on your left. I'm doubting myself there. No, the second, third one, center on your left. Left, please. Third one. This one? No, on your, this, if you, there, band neutrophil. Below the band neutrophil. Below the band neutrophil. In the center. Below the band neutrophil. There is the band neutrophil. Below that. Yeah, yeah. Down one. Down, please. Yeah, down one. If you, if you move the arrow down in the slide, please. What kind of this seems like? Say, look, a. Yeah, this one. Where your head? A. Yeah, this one. One second. Okay. Lymphocyte. Looks like. Okay, it looks like lymphocyte. I think so. I'm not sure. So how would you report it? Oh, reporting. Okay, that's quite a difficult part. I'm learning, but I'll tell you the same. I think most of the cells look hypochromic, microcytic cells, and you can see the few of the spherocytes. But I can't see here. The previous image I saw. And there is the abnormal shift lymphocyte as compared. So would like to do immunophenotyping? Okay, that's the only thing I can suggest. And platelet count is, look, see the size of platelets. Look, it looks okay. Yeah, anything else? I think so. So this patient's count is 66 white blood cells. If you go through there are the. I think the lymphocytosis with left shift and abnormal lymphocytes. And, uh, platelets look, size is fine. Everything looks okay. Nothing microcytic hypochromic anemia. This. Okay. 45 years. Yes. Anything else you can tell me? This is. So these are all mature lymphocytes as the nuclear material is compact. They are dark looking. There are no nucleoli in them. These are mature lymphocytes. The patient's white cell count is 66, and there are a few spherocytes in the red cells as well. The platelet count is on the lower side, and you have seen few smear cells as well, um, in the, in the slide. You will say in your report that the blood film shows lymphocytosis. The lymphocytes are mostly mature with no nucleoli and clear cytoplasm. Multiple smear cells are noted. The red cell morphology is okay except for few spherocytes. You cannot say whether they are small or big because there is no normal. Yeah, okay. Okay, that's good. No platelet clumps seen, but the platelet count looks low. The blood film is most likely consistent with, um, a mature lymphoproliferative disease. A proliferative disease, likely, uh, CLL. We need to send the blood to the flow for the flow to confirm our diagnosis. This. Yeah, you, you have mentioned the findings, you have suggested a probable diagnosis, and you have suggested, uh, some tests as well to confirm your diagnosis. This will complete your report for the FC exam. Yeah, okay. Okay, that's great. So what is the expected flow cytometry for this case? Lymphoproliferative disorder. CLL. Chronic lymphocytic. Chronic lymphocytic leukemia. CLL. Think CD200, CD3, CD4. If I remember correctly. I'm not sure if I remember correctly. So CLL has, uh, markers. Panel which contains CD5 positive, CD23 positive, CD43 positive, 200 positive, and, uh, surface immunoglobulin which is weak. Okay. Not 3 OH 43. Sorry, you're right. Thank you. So remember 5, 23, 43, 200 for CLL. Then you will not forget it. 40. Yeah. So the last question is, uh, you call the patient. Patient says he's completely fine. He has no B symptoms, no lymphadenopathy. He is doing his job normally, no problem with him. His white cell count is, uh, 66, and the flow cytometry confirmed your diagnosis of CLL. Would you like to treat this patient or not? I think it depends upon the staging of the patient. If everything is fine, nothing is there, then likely I think WBC count 76, and, uh, wait and watch. You can choose or you can just give. I think just wait and watch. Okay, let's see how he's doing. Yes, if CLL patient is asymptomatic, then no need to treat. Just monitor the count. And, uh, the guidelines have some indications for treating the CLL patient. So you need to go through these points. What are the indications of, um, treatment in CLL? Yeah, sure, sure. Yes, if lymphocyte doubling time is less than 6 months, or if the, uh, than 2 months. If the patient starts to develop progressive cytopenias, massive splenomegaly, or massive lymph nodes which can, which can compress the vital structures like any nerves, blood vessels, in such cases, you would think about, uh, starting the treatment for the patient. Yeah, sure. Okay. Yeah, sure, sure. Thank you. This 43. Sorry. I have a question. Yes, go ahead. Why this case can't be a viral infection like EBV infection, as the cells are mature looking and they have abundant cytoplasm and their cytoplasm is scalloping around the RBC? Why can't it be on morphology if we are not sure whether it's a lymphoproliferative disorder and we have a differential in our mind of a reactive process as well, and how we are going to report such case if we have a doubt whether it's a clonal or it's a reactive thing? So, uh, I think I had shown you the, um, the infectious mononucleosis or reactive patient's blood film. They do not have a count of 66. Their count is usually 11, 12, 13, 14, like this. Secondly, the cytoplasm in reactive lymphocytes is a bit basophilic. This cytoplasm is very clear, and if you go towards the thicker side, they become small and small, just like the typical CLL cell. You will not see such features in viral infection. Thirdly, like the question mentioned to you that you have called the patient, patient says I don't have any symptoms. If he had any viral infection, he would have told you that he had sore throat a few days back or he had flu or currently he has some infection going on. And the last, um, supportive thing was that you, the question mentioned to you that the flow cytometry confirmed the diagnosis of CLL. And in the next lesson, we will see the infectious mononucleosis or reactive blood film again to show you the difference between these cells and the infectious mononucleosis or reactive lymphocyte cells. Okay, as the morphology of these cells is not very classical typical of CLL, yes, but the cells are mature, and as you go towards the thicker side, the, the size of the cells get shrink and shrink and small CLL can have some prolymphocytes as well, which are bigger than normal and they have nucleoli as well. But this case, the cytoplasm was abundant, but the nucleus was very mature, but it was not basophilic as we usually see in the reactive lymphocytes. And the reactive lymphocytosis does not have counts like 66 or 76. The count was very high in this patient. You cannot call it as reactive lymphocytosis. Okay, okay. So now.
So, this is the third case. This is a 41-year-old patient who had a bone marrow transplant for MDS with excess blasts. He was well up till now, post-transplant. His transplant was 2 years ago. You have seen him in the clinic today, and he was feeling a bit tired. You send a blood test for the patient, which shows pancytopenia. Hemoglobin 88, white cell count 1.2, platelet count 88, and this is the blood film. So, anyone who wants to go ahead? Okay, I will do it. Right. So this is the power 10. I will, okay, I will just move around and then I will go to power 50. Because the patient is pancytopenic, we may not see a lot of cells in this slide. What was the count? Could you repeat? What is the hemoglobin? Hemoglobin 88, okay. PLT 89, white cell count 1.2, neutrophils 3. Okay. Uh, red cells are normal and iso, occasional macrocytic cells are seen, and it appears reduced. I want to see any fragmentation because post-transplant, must be on, um, immunosuppression. So is there any MAHA like, because thrombocytopenia, he has pancytopenia. Yeah, it's pancytopenia. I can see clearly some. There are few macrocytes, and otherwise, it's normocytic and iso, and I can see neutrophils and few lymphoid cells, uh, on this, uh, in these pictures. I could not appreciate if there's any blast cells, and platelets are reduced. Do you think these neutrophils are normal? This one is hypolobulated and hypogranular. They are dysplastic. Yeah, but few are like previously. This is a typical cell. I'm not sure whether it's a blast or, but it is definitely not normal. This could be blast. So this one has a nucleolus. Yes, this is blast. So the blast percentage is 8%. Okay. Yeah, blast. These, there are blast cells, right? So you'll see this one, and then you can report the blood film. Now you can start reporting the blood. Yeah, the blood film shows pancytopenia. Red cells are normocytic and iso, occasional microcytic RBCs can be appreciated. White cells are reduced, but there are blast cells present on the smear, and neutrophils are dysplastic, hypolobulated. Platelets on smear reduced. And otherwise, yes, this is at all. And the film is conclusively suggestive of, um, relapse, as it's a post-transplant slide. Okay, so the blood film contains multiple blasts, yes, with low red cell count and low platelet count. There are multiple dysplastic neutrophils present as well. The film raises the suspicion of a relapse disease, post-allergenic bone marrow transplant. We need to, uh, admit, we need to do further investigation to confirm this relapse, like sending blood for flow cytometry and bone marrow aspirate and biopsy. Okay, so now I have told you that, um, this patient has 8% blasts, and he has dysplastic neutrophils as well, and his previous disease was MDS with excess blasts 2. Okay. Do you think, do you think this still fits in a category of MDS excess blasts 2? No, it's a blast, but I have to check the bone marrow, not on the peripheral. On bone marrow, if the blast percentage is 10 to 19%, then it's excess blasts. You have to check the cytogenetics as well. Has acquired any cytogenetic abnormality that fits him into a category of AML? If not, then he will be, uh, relapse MDS excess blasts 2, because the blast percentage requirement for MDS excess blasts 2 is 5 to 19% on peripheral blood and 10 to 19% in bone marrow. Bone. Yeah. Okay, so the bone marrow has confirmed that this is relapse MDS excess blasts 2, and, um, the question is, what are the treatment options here? Yeah, it depends like, uh, what is the again, cytogenetics? It's a whether it's a good prognosis, intermediate, or poor prognosis. IPSS. It's a low-risk, intermediate, or high-risk group. And patient has already received one allogeneic transplant, and if the blast count is on the lower side, like, um, less than 20%, we can option, we can discuss with the patient and previous treatment toxicities, patient performance status, comorbidities, and patient already received allogeneic, then, uh, second allo could be the possibility, or the hypomethylating agent could be the possibility, because the blast count is, as you said, it's on the lower side, right? So you would say the patient supportive treatment. So you would say the patient needs reassessment for fitness for any further chemotherapy. Yeah, and the patient's wishes as well, whether he, yes, wants to have any further chemotherapy or not, either intensive or non-intensive. Assessment of the patient organ function by doing routine blood tests, echo, LFTs, liver function tests, and his general condition, because he may be frail, looking not fit for any intensive chemotherapy. After that, you can give him an option of, um, venetoclax, because the blast percentage is less than 30%. You can give an option of a single agent hydroxycarbamide, or you can palliate him. Yeah, after discussing the patient in the MDT. But venetoclax is for AML. Can we give it in this? Like, in the guideline, venetoclax is not mentioned in MDS. Yes, venetoclax is not here, but single agent you can give. Yeah, hypomethylating agent or, then there are other options like for palliative care like low-dose, and, yes, depending upon the patient's agents, you can offer a single agent or palliation for the patient. Okay, okay. So MDS was not in the exam last time, so be ready for it. Yes. So this is the second last slide. Right. So this is again a GP sample. The BMS referred the blood film to you because he has seen multiple abnormal cells in the blood film. The full blood count of the patient is hemoglobin 110, white cell count of 26, and platelet count of 150. Okay. Who wants to go ahead? Okay, I will do it if nobody else is, uh, ready. Okay, anyone can chip in. Uh, yes, no issue. Okay, um, you told, um, hemoglobin 110, and platelet 150, and what about the TLC? It's 10. It's 26. 26, okay. So this is the power 10. I will go to power 50. E. E. E. Blood film. Red cells are normal and iso, and there are few, I can appreciate. I don't know, it's a few macrocytes like this. And the white cells are increased. Neutrophils are present, but they are hypogranular and some dysplastic features can also be present. There is, uh, increase in monocyte count. There is monocytosis as well. Platelets are present. Yes, there are monocytes. Okay, now report the blood film. Yeah, the film, film shows the increased white cell count, uh, with hypogranular, hypo dysplastic neutrophils, and increased monocytes or monocytosis. White cells, red cells are normocytic and isocytosine. Sorry, what was your suggestion that the film is consistent? My suggestion was the film is suggestive of myeloproliferative neoplasm, slash MDS, or query. Can I mention here query CMML after MP and MDS slash? Can I mention it's, uh, suggestive of CMML? Yes, why not? Okay, shows, um, we need to send the bloods for flow cytometry and need invasive investigation like bone marrow biopsy for confirmation. What is the WHO 2022 criteria for CMML diagnosis? Uh, it is more than absolute monocyte count more than 1,000, persistent more than 1,000, or more than 10% of the total WBC count, and there is no BCR-ABL, PV, and primary myelofibrosis, and there is no myelolymphoid neoplasm with the tyrosine kinase molecular, like defects. And there is, this is the prerequisite, and then there is the supporting criteria. If the more than 1,000 neutrophils, monocyte count, then any of the supporting three criteria is acceptable. But if its monocyte count more than 0.5 but less than one, then all three supporting criteria are present. Supporting criteria is dysplasia in one or more lineage, and, uh, there is a clonal cytogenetic abnormality, and abnormal partitioning of, uh, monocytes. This is CD14 positive and 16 negative. Yes, so the diagnostic requirement is that the patient should have monocytosis more than one, plus either you should have a dysplastic lineage in one of the, uh, cell, like we have neutrophil dysplasia here, or you should have a clonal genetic defect on bone marrow biopsy cytogenetics. Then, uh, you have met the WHO 2022 criteria for diagnosis. This is, this is CMML 1 or 2. It is 2, because the WBC count is more than 13,000. If no, no, if more than 30,000, it is, uh, proliferative CMML. And if the blast count is less than 5% in the peripheral blood, then it is CMML 1, and if it's more than 5% and less than 19%, then it is CMML 2. And in bone marrow, it is less than 10% is 1, and more than 10% but less than 19% is 10 to 20% in CMML 2. So, meaning the blast count in the peripheral blood. But yes, so subgrouping is on depends on the blast count, and subtyping depends on the white cell count. If the white cell count is more than 13, and it is a myeloproliferative CMML type, and if the blast count is less than 5% in peripheral blood, it is 1. If it is more than 5% less than 19% in peripheral blood, it is CMML 2. Yes. Okay, so the last question is, what is the prognostic score that you use in CMML? Prognostic score, I guess it is, uh, dependent upon molecular lesions. SRSF2 is poor prognosis. ASXL1 is poor. And I asked you, what is the name of the score that you use for CMML prognostic? No, I think CPSS. CPSS. Mo which includes cytogenetics like ASXL1, EZH2, RUNX1, SETBP1, plus bone marrow blast, peripheral blood white cell count, and transfusion dependency. Okay, yeah. So this one, it came in the last exam, so this time it can come in the W section or in the long cases, where it will convert to a full frank AML. So the last question, we'll do it quickly. Right. So this is a 55-year-old man, uh, referred to you by the GP because of low counts and splenomegaly. So the next on the list is Nah. You want to go ahead, Nah? Uh, hello. Yeah, um, can you give me the counts? How much they are low? Hemoglobin and TLC and platelets? Because the TLC seems to be quite high. Like it doesn't seem that it's the patient is having cytopenia. So the hemoglobin is 98. Okay. White cell count is, um, eight. Eight again. And platelet count is, uh, 130. Okay. The white cell count is 8,000. Yes. Okay. This is the power 10. Okay. And then I will go to, uh, power 50. Just have a look. Now, 50. The patient has some Howell-Jolly bodies as well because he has CLL. Okay, okay. Yeah, the red cells seem to be, uh, normocytic and normochromic predominantly, and, uh, the pre, uh, the white cells, they are mostly lymphocytes having abundant cytoplasm. Some of them are showing cytoplasmic projections as well, like, uh, hairy cells. And the platelet counts are, uh, it seems to me normal, but, uh, yeah, they are like 150, 160. Okay. Report the blood film. Okay. Uh, blood cells are normocytic, normochromic. WBC, predominantly lymphocytes having abundant cytoplasm. Chromatin is condensed with condensed chromatin and abundant cytoplasm, having some of them, most of them showing cytoplasmic projections. No neutrophils seen so far. No, no neutrophils. So neutropenia, I can say. And, uh, platelets are adequate on film. Why you say neutropenia? There were few neutrophils. Yeah, but, uh, but they were quite less as compared to the lymphocytes, and I, I didn't like see the differential, but I think they are a bit low because we see, we see. You mean monocytopenia? No, uh, neutropenia because I haven't seen, I, I saw only one or two neutrophils, and usually they are the predominant cells that we usually see on the film, but I, I think there is no this, which is the feature of this condition. Yeah, monocytopenia. Yes. Condition of, yeah, in Hairy Cell. Okay, so I, I would advise the blood, the blood film contains, yeah, multiple mature white cells with abundant cytoplasm and hairy projections. Yes, there is monocytopenia. Some of the red cells show, um, Howell-Jolly bodies, signifying hyperism. Yeah, the platelet counts look normal to low. There are no platelet clumps. The blood film is most likely consistent with lymphoproliferative disorder, most likely Hairy Cell Leukemia, or or we have to directly say that, uh, Hairy Cell Leukemia predominant, most likely consistent with Hairy Cell Leukemia, which needs to be confirmed on further tests like flow cytometry and bone marrow aspirate and biopsy. Yeah, and molecular as well for I don't know where they do it. BRAF V600 mutation, which is present in 100, almost 100% of the patients of Hairy Cell. Okay. All right. So one of your colleagues in this meeting says, no, the he is wrong. This is not Hairy Cell Leukemia, this is Hairy Cell Leukemia variant. How would you defend yourself that this is Hairy Cell Leukemia, not variant? In Hairy Cell Leukemia variant, we usually have high WBC count, like here the patient is having like cytopenia, and, uh, in variant, we usually have high WBC count, and I don't remember the other. There was a whole list of differences between Hairy Cell Leukemia variant and Hairy Cell Leukemia, but at the moment, I don't remember any one of them. So, so for exam, for exam purpose, you need to remember them. The, there is no Hairy Cell Leukemia variant. Now, if you are following WHO 2022, it is called splenic lymphoma with prominent nuclei, which means that they have prominent nuclei, less cytoplasm, no monocytopenia, no BRAF V600E mutation. At least four or five differences are there. Yeah. Okay. What flow cytometry do you expect in this case? CD25 positive, 103, 11C, 103, 11C, 125. And B, there is no marker as 125 yet. Sorry, sorry. I'm a bit out of touch because I'm not actually preparing for part two, but I was listening it just for a part of passive learning. So, yeah, no worry. So it's 11C, CD25, 103, 1, and 123. This is the Hairy Cell panel, which contains four markers. Okay. And what molecular mutations is present? It's BRAF, V600. V600. And, uh, E. You have to write E as well, otherwise your answer will be wrong. Yes. So, would you like to treat this patient or not? Uh, the patient, the counts are normal, like they are not that. If he's symptomatic because of the splenomegaly or as long as the patient is doing well, we don't treat him. But if the patient is having fever or clinically he is symptomatic, then we usually treat the patients. He is symptomatic. He has a big spleen to an extent that he has developed Howell-Jolly bodies in the blood film. Yes, right. So you have started him on the treatment. The last question is, how would you monitor the treatment response? By, um, first of all, by monitoring the, if all although he is asymptomatic, but we can see the changes in the blood counts if they are like he's a bit cytopenic, so if they are improving, and by monitoring the size of the spleen. You can monitor the patient either by flow, which is used, not that common, or by repeating the bone marrow biopsy at four to six months to see whether your treatment has worked out or not. So in the bone marrow, what we are going to see, like the percent, percentage of cells, or what? Do you know what are the features of Hairy Cell Leukemia in a bone marrow? Yeah, we usually, like in the trephine biopsy, we see such, these hairy cells showing a particular feature called a fried egg appearance, that's quite like typical of it. And, and fibrosis, as well. So, so the trephine has fibrosis. Yes, appearance of the hairy cells, and the aspirate is very difficult to get from these patients. The aspirate is a dry type, usually. If your patient is responding to the treatment, you would be able to get some aspirate after four months or after six months. Okay. Okay, yeah. So the dry nature of the tap would go down, and if you review their, um, bone marrow biopsy and trephine, the fibrosis content would have gone down as well. Okay. Okay, yeah. All right. Right. So this was the session five for morphology. And the next slide is that this session, these sessions are all free, and I want to keep them free. But if you want to donate, these are the account details. And the last thing is that thank you, and please like, share, and subscribe the channel, and we will meet next Sunday again with another five cases. Thank you very much. That was great. Thank you. Thank you. Thank you.