Transcription
What GRE? How about Green? Look, yeah. So this is the first case. Um, in the last session, one of the candidates asked about the difference between uh septic picture and CML. Uh, but unfortunately, she's not there today. So this is a uh 46-year-old male admitted to ICU with biliary sepsis. The WBC count is 44 and the platelet count is 600, and hemoglobin is uh 99. This is power 10. Deficient neutropenia, thrombocytosis. What is the HP? HP is 99. We go to higher power to see the cells. Target cells. So how a lab person will report it? Let's see a few more sections. And then neutropenia with rososis. Query. Uh, success. It's platelet anisocytosis. You know, one or two spherocytes. About two. I think the neutrophils are showing toxic granulation also. Yes, there is thick granulation in the neutrophils. It's not a typical toxic granulation. No, on the osis that goes with the anemia. I thought there might be a few more on the sites about, but I haven't seen one yet. F, what's the CRP? 385. So, one, two, three, four, five, six, seven, eight, nine, ten. Ten hyposegmented. What is B12? 8. B12 was normal, but the folate was low. Three less than four is low. In this neutropenia, I think you just skip from is it bated? Maybe this plastic. This one. This the connecting uh nuclear material is not very thin, but you do see some new new plastic. This plastic neutropenia in sepsis as well. So I will make this little field big to see if these are death crystals or sh. No, I think this is just the shadow of the RBC behind it. I was thinking maybe these are the death crystals that that are present in the severe sepsis. That's S L stage though, isn't it? M. It's not a good sign. Organ failure then. Yeah, if there is multi-organ failure, then these death crystals do appear. Uh, one more hypersegmented neutropenia. Fate deficiency. The patient had low folate. We thought that segmentation is because of the low folate. This patient's coagulation screen was abnormal as well. So what was the fibrogen? The coagulation fibrogen was low. It was um 1.0 or 1.1, like that. In severe sepsis, we would we should expect fibrinogen to be like four or five because it is an inflammatory response, um, uh, thing. It should be high in the in the uh severe sepsis or infection. And if it is one only, then that is low as well. This patient is in DIC because of the abnormal coagulation picture. And uh, there were side. I'd expect to see more fragments though. Um, yes, that I was looking for, but I could see only two up to now. Platelet count still high. SC are high. You can say this is to yes. So you see B hypochromasia, RS here in this section because of DIC. He is uh mizing his blood and I think iron content is going low as well, but I do not remember the iron level. So in DIC, you do see fragments. The platelet count will be high because of the in infection as a reactive response. The WBC count will be high, but it will be mostly either neutrophil or band form. Sometimes myelocyte do appear, but not always. And you need to check the coagulation profile as well to see whether it is DIC or not. There's a dot here, which means this blood stream relates to female, right? This is a Barr body. Yeah, if I remember correctly. Yeah. What happened? Sorry, sorry about this. Sorry. Carry on. Thank you. It's just asking about the thrombocytopenia because it's part of the M of the DIC. Maybe early in sepsis, the thrombocytosis, but because of the DIC, it might be more thrombocytopenic. In DIC, if it is because of the bacterial infection, then sometime you see thrombocytosis as well. Thrombocytosis is common in bacterial. If it is a fungal or viral related sepsis, then you will see thrombocytopenia. Maybe this is initial stage, that's why his platelet count is high. Yeah, but as a as a response to infection, the platelet counts goes high always. But if it is a virus thing, virus always suppress your bone marrow and the there is to one fragment is there. Just no. So you will report the blood film for the exam purpose that uh, this this blood film contains leucocytosis and thrombocytosis. There are multiple shistes in the blood. No blast. Multiple uh toxic granulation in the neutrophils. Multiple toxic granulated neutrophils and uh band forms. In there is anisocytosis. The uh impression is likely uh reactive response to infection. Please correlate clinically or check the infection marker and coagulation screen for the thing. That's about it. Yeah. So normally, the people in the exam make a mistake. They see that the uh WBC count is uh 50 plus. This must be a CML and they make up things. So high WBC count doesn't mean that this is uh CML always. It can be a reactive as well.
Now to compare the previous slide with this slide. So this is again a young person, 30-year-old, with white cell count of 400. Can we have a closer look, please? We go. This is a plastic picture. I think this is CML. It's a different. There is left shift. There is metamyelocytes, myelocytes, bands. So this one is a neutrophil. This is a band form. This is a myelocyte. There is a dip here. It can be metamyelocyte. This one is a myelocyte. This big one is uh promyelocyte. And we have yet to see a blast. And that's a blast down. I think here. This field I'm seeing any uh pH of NRBC of the high bone marrow activity. And looking for eosinophils. I see one there now. Yeah, this one looks like eosinophil. Orange granules. And in this [Music] one there, there are a couple there. More that this one very there. And this one as well. Very related. Not sure about this one. Yeah, yeah. And this one is loose. This one well. So they can ask you in the exam, uh, the difference between a CML and a leukemoid reaction picture in the. So you have seen the previous blood film whose white cell count was high and this blood film whose white cell count is high as well. There is basophilia and whole myeloid peak, which you which you didn't see in the uh septic picture of blood film. And the basophil is the main differentiating point between uh leukemoid reaction and the uh CML. Why are there more basophils in CML? The 922 translocation and mutation result in formation of all myeloid peak including basophil, eosinophil as well. H. This is the only explanation. So how will you report this blood film? Um, can we see a lymphocyte just to compare with the the size of uh RBC? Lymphocyte. It would be very difficult because the film is full of myeloid peak. Uh, maybe this one is a lymphocyte, but this one is NRBC. This one looks like a. And it, uh, size is all same as the NRBC as the red cell. And the size of the nucleus is same as the red cell. This is normal setting. Yes. So normocytic, normochromic anemia. Always comment on the uh abnormality first. Okay. We'll say leukocytosis or leukemoid reaction with the bands, metamyelocytes, myelocytes. I think the blast should be uh noted as well. Yes. The blood contains leukocytosis. There are multiple neutrophils, band form, metamyelocytes, myelocytes, promyelocytes, blast form, multiple NRBC along with basophils and eosinophils. Platelet count is slightly increased. Red cells are normal. The blood film picture is consistent with uh most probable diagnosis of chronic myeloid leukemia or you can say it is most likely a myeloproliferative neoplasm, probably chronic myeloid leukemia. We need to send peripheral blood for uh BCR ABL1 screening. You will confirm the diagnosis by BCR ABL1. Then in further part, to short questions, they can ask you, uh, what are the poor prognostic factors in CML? What are the prognostic tools in CML? And we have Sokal. Yeah, tool. Sokal. Sokal. Yeah, HASP and ELTS. The current one that we use in practice is ELTS. And uh, there are some poor prognostic cytogenetics which are called major route abnormality. And then they can ask you about uh treatment options. What to use as a first line? In this station, they can ask you what is the criteria of treatment free remission that we discussed in our yesterday session. The reporting usually carries uh five marks and the rest of the marks are for this small question. CML is quite common. You must have blood films in your uh TR or in the uh, Nicose folder, but it do come either in the WBC or in short question in the in the part exam. So you have 9 minutes in the short question and in these 9 minutes, you have to see a blood film and you have to answer the question. As you need to be very quick in the exam.
This is a 40-year-old lady with a hemoglobin of 180 and white cell count of 13. Platelet count of 380. Polycythemia. Yeah, yeah. I would like to ask you if you can tell your colleagues how do you define this as polycythemia? What are the features that made you think about this is polycythemia? Well, the actual red looks really high. Hematocrit is probably high too, the looks of it. Hematocrit above 49% in female and 52% in male. The one clue is that that they will give you FBC which will show either high hemoglobin or high hematocrit. Second clue is that the red cell mass is very high in the blood cell and you can see these red cells have uh different shapes like there this is called stacking of red blood cells like you are keeping bricks on one on the top of one another. So they have different side shapes, some are straight, some are regular round one because the mass is very high and they are compressed together. In the other blood films, they were all normal red blood cells, but here they look like you have um pieces of marbles in the in the wall with different side shapes or or in the books, it the term is mentioned as stacking of red blood cells. That can be quite misleading because you could think it be rouleaux because that's another term for stacking of coins. The rouleaux. These are attached to one another. H. Yeah, one is not attached. If you can see this uh red blood cells, they have very different shapes according to the neighboring RBC. They look like compressed to one another. Like this is not a regular shape of RBC. This is not a regular RBC shape. This is made because they are they are too much and they are trying to adjust themselves here. Right. So what will be the next step after seeing this blood stain? I certainly requested JAK2. If I say no, I don't want to request JAK2, there is something else that you need to do. I examine the patient for myeloproliferative neoplasm. Why suggestive of myeloproliferative neoplasm? So whenever the counts are high, do not jump to MPN directly. There is always there is always secondary causes like for example, dehydration. Is the patient dehydrated or no? And then we go for smoking. OCP. Yes, the patient may be very obese, may be having um sleep apnea, smoking, taking steroids for Gout, maybe having a COPD or any known solid organ cancer secreting a lot of erythropoietin. Maybe maybe he has this diagnosis since birth, congenital polycythemia. Always exclude the secondary causes of erythrocytosis. And then you can send the de to for the patient. So this if this patient is a smoker, then uh refer the patient to GP for smoking cessation program. If it if it helps the uh if if the program helps the patient by quitting the smoking, his cell count will come down. If the patient is known to have COPD or sleep apnea, very or any pathological cancer, his count will be high. The main important thing here is to check erythropoietin level of this patient. If the erythropoietin level is low and cell count is high, it means there is some malignant element is involved. If the erythropoietin level is high and this is the blood picture, then I would think this is secondary polycythemia because that cause leads to elevation of erythropoietin and now as a response, the uh red cell count is high. Similarly, in thrombocytosis, you exclude first the secondary cause. The common cause of thrombocytosis in UK is iron deficiency anemia or infection. And rule out the other causes. If no secondary cause found, then you contact the HMDs for MPN panel or JAK2. So if you jump directly to uh MPN panel or JAK2 in the exam, uh, they will not give you marks because in our routine practice, whenever we have high uh counts, we always ask them, is there any secondary cause in this patient or not? We open the BCO app and the BCO app has a lot of uh, a lot of uh causes of these things. Things. I hope you know about BCO app. It is a very good app for hematology on call.
So the next blood film is um 24-year-old male with uh fever and cervical lymphadenopathy. Sorry for interruption. So B AB B KU B U KU. Great. Thank you. It you this one book medicine and it has different specialties including hematology as well. Yeah, there is an application also. You can download it to your phone. Yes, there is a book app. You can download it from the uh application store. Great. Thank you. This is lymphoid. Yes. So this patient has lymphadenopathy and this is the blood picture. Can the large platelets? Yeah, platelets are a bit low. So so what comes to your mind when you have a 24-year-old patient with cervical lymphadenopathy? What are your differential diagnoses? Infectious mononucleosis, other viral infections, uh, lymphoproliferative disease like lymphoma. And um, yeah, this is what came in my mind. What comes to your mind? Hodgkin's. Yes, Hodgkin's is common in young. All your Hodgkin's patients will be less than 30. Yes, and they have either cough or mediastinal mass. So this is a quite large lymphocyte, but it has a basophilic cytoplasm and it is coping this RBC. And this is a mature one. And there is no blast in it. What is the lymphocyte count? Lymphocyte count is the white cell count is 13. The lymphocyte itself is five. That looks a bit atypical, molded around the red cells. So this is another phenomenon called scalloping of the red cell cytoplasm. Cytoplasm is basophilic. There is no nucleus, no nucleoli in this cell. And these are the features of reactive lymphocytosis. So what test you will do to confirm your diagnosis? Blood culture. Why to exclude? What what probably? Sorry, exclude what? Usually we use the flow cytometry to exclude CLL or we can yeah, other markers also for the uh B cell. CLL does not appear like this. CLL has very small lymphocytes, very small cells. Yeah, it's not like this. Very small lymphocytes. Usually the size is just like the red cell and they are quite many. Like the CLL counts are always about 20. Extreme cases are in 300, 400 as well. And CLL doesn't happen in 24-year-old child. Sorry, uh, patient. This is reactive lymphocytosis. I was thinking about EBV infection. Yeah, Monospot test. Monospot test. Yeah, yes. And to exclude other infections, you will send HIV serology, Hepatitis B and C. What's the CRP like? CRP was just 25, I think in this patient, as far as I remember, because it's a virus, the CRP usually does not go high. It's not a classic case though. Sorry, this is not a classic case of uh, like glandular fever. I'd expect bigger cells, more basophilic cytoplasm. Yes, maybe. Is it? I think this is the biggest they are as well. And there is no other bigger than this cell. That one that one was the biggest one. And this is another one which is big. It depends on the virus as well. If you have seen the blood film of a whooping cough baby, it has smaller cells with deeply basophilic cytoplasm, just like the cytoplasm of B lymphoma cell. It depends on the virus as well. This is quite large cell and the cytoplasm is bluish. There is no nuclei, no granules even. And there is uh typical coping here, scalloping here, this one and that one. And the history matches uh infectious mononucleosis as per yeah.
So this is a 70-year-old patient with progressive fatigue and paraprotein was 66. We thought that this may be myeloma. We did a bone marrow biopsy for her and this is the aspirate which is particulate. You can see the particle here. This is power 4. Aspirate smear and suspected blood film of a worm. You need to see on power 4 first for aspirate to see whether there is any particle or not. The worm, the worm blood film, you will see the worm on power 4 first. And smear at power 4 will tell you the cellularity of the bone marrow. So this aspirate is quite cellular. You can see a lot of cells here. This was particulate as well. And let's find a thin area to see the cells. See what do you think of these cells? All right. So this is the thinnest area in this aspirate. Any comment on this aspirate? There is neutrophil. There is myeloid maturation is present. These are few side. But is this cell? This one? Those are nuclear RBC. And this is plasma cell. They make it big for you. This was a slide that I was talking to. This is a one-sided nucleus, cytoplasm and a halo here. This is a plasma cell. That's a plasma cell. It's got the egg shape, right? Egg. Quite a lot here. This one. These one are distinct plasma cells with two nuclei. These are all plasma cells. This patient had uh 40% of the plasma cells in the bone marrow and the CRAB criteria was positive. Calcium was high, renal functions were abnormal, anemia was there, and there were five lytic regions on the uh low dose full body CT scan. And the paraproteins were IgG as well. It fits the criteria of myeloma. And she had 14 16 translocation, which is relatively considered as a poor prognostic. Was there a plasma viscosity done? The plasma viscosity was three in in her because she was already on a blood thinner for a DVT. Maybe that's why the paraprotein was a bit low. Sorry, am I? Is it the flame shape plasma cell for typical for a? The flame shape is usually which I have seen common in the in the bone marrow, but the book have mentioned flame shaped cells in IgG. But I, yeah, but I have seen most of them in the bone marrow, not in any other. Like these are plasma cells, but this is not flame shaped. Only these few projections here, but I will not call them as a flame shape. Typical flame shape. I think like with the spindle projections. Yeah, yeah. But most of them are without any projection. You can you can remember it for the exam purpose, but my practical experience in terms of like this one has many projections on the top left, both these. Yeah, it looks more of flame shape. Yeah, yeah. But most of them are without any projection. Sorry, I don't have the smear of this patient because bringing out smear is a bit difficult because of legal purposes. As for it, we can stain aspirate cells in the laboratory. We bring out as this is binucleated plasma cells with eccentric nucleus with a halo. Now, there these cells have subnuclear vacuoles inside them. This one and this one. There was a time used for these cells, Russell bodies or something like that, but I forget. Yeah, Russell bodies. And there was one another term as well because one of them is intranuclear and another them is intracytoplasmic. Many of them. But those are the features of Mott cell. Not commonly seen in multiple myeloma patients. All right, so we are on time today. We have done five cases. We will stop here. Is there any question? Thanks again. So next week there will be no morphology session. It will be a session for the part two people. How to prepare part two? After that, we will resume our. Okay, thank you. Okay, thank you. Appreciate. Bye. Thank you. Thank you.