Transcription
All right, so let's start. Welcome everyone to Session 8 for morphology. This is for both FC UK exam candidates and for the lab staff. Let's start with the first case. I would need five volunteers for the case description. They can be both clinical hematologists or lab hematologists, no issue.
Right, so this is the first case. This is a GP blood sample who has been sent to your hospital for assessment. The patient went to the GP because of um continuous and ongoing fatigue and tiredness. He is 80 years old with comorbidities of ischemic heart attack um 5 years ago and he has um chronic heart failure as well. So, 80-year-old comorbidities of um cardiopathy and um nephropathy. He has ongoing tiredness and this is the blood film of the patient. Right, so I would need one volunteer first to comment and report the blood film.
Oh, so there's an increase in lymphocytes. Okay, so you are Dr. Simam or Dr. FMA, who is speaking? Simon, right? So this is power 10. I will go through the film to give you an overview and then I will move to power 50, which is an oil lens with me, and then you can comment or report the blood film. Right.
Uh, sir, there is rouleaux formation and, um, as these lymphocytes appear to have their nucleus pushed to one side, so maybe it's plasma cells. These are all now power 50. So this is the cell. This appears to be lymphoplasmacytic. See, see some more and then you can report the blood film.
For the GP, I can appreciate the hairy projections along the cytoplasm, circumferential. Am I right? There is some projection from this cell. Okay, so these are three more cells. Right, these are lymphocytes with the circumferential um projections of cytoplasm. Sir, this is eosinophilia. Yes, sir. The cells are having eccentric nuclei and there is a perinuclear halo and intensely basophilic cytoplasm and, um, I would go with the probability of plasma cells and RBCs are showing rouleaux formation. Okay.
All right, so are you a hematologist or a lab staff? Uh, sir, hematologist. Dr. Habba, right? Now you are sitting in the FC part two exam. The first question for you would be, report this blood film. This is a six marks question. Okay.
Um, sir, this, uh, is the blood film of, uh, this is a peripheral blood smear which shows, uh, increased white blood cells count and majority of them are, uh, plasma cells. And I also appreciated a few neutrophils and a monocyte. And, uh, red blood cells are normocytic, normochromic and, um, is showing rouleaux formation. And, um, platelet count is also adequate. The peripheral, uh, film is suggestive of plasma leukemia. And bone marrow aspiration and trephine biopsy, uh, is advised for further confirmation of diagnosis and for cytogenetics and FISH. In cytogenetics, we would go for, uh, three translocations of 4;14, 14;16, and, um, 14;20 translocations. Also, I will, uh, go for the workup of, uh, serum protein electrophoresis and, um, immunofixation.
So, the question was to report the blood film. You have only 9 minutes in the exam to, um, attempt this question, which will include reporting the blood film and a few other, uh, parts as well. Oh, okay, sir. So, so the dominant feature is increased in plasma cells in this patient. The blood film shows leukocytosis or increased number of plasma cells with rouleaux formation. The red cell morphology is normal with, uh, normal platelet count as well. There is no platelet clumps. The blood film is most likely consistent with plasma cell leukemia.
You are saying plasma cell leukemia on the basis of, uh, sir, the, on the basis of plasma cell count. If the, yeah, so the blood film most likely can say with, with plasma cell disease, likely plasma cell leukemia based on the plasma cells present in the peripheral blood. Further investigation, this patient needs further investigation like blood for flow cytometry, uh, and bone marrow aspiration and trephine biopsy. This patient needs to be assessed urgently by a hematologist.
So, this was the report that you would mention, uh, in the, in the exam. You comment on the blood cells, you, you commented on the, um, your impression, and you give some plan as well. That will complete your, uh, your report of the blood film. What about the projections around the cytoplasm? Do we see them in plasma cells as well? Yeah, so plasma cells, lymphoplasmacytic cells, hairy cells, um, and even the, uh, the Babby cells of TPL, they are all known to have projections. But these cells are characteristic plasma cells because they have, um, this whitish halo, yes, whitish here, which is the Golgi zone, very basophilic cytoplasm, and nucleus is usually to one side. But, but there may be variation in the plasma cells morphology as well. Some of the, uh, nucleus may be in the center, not towards one side. But most of the plasma cells here in this film were having, uh, are having eosinophilic cytoplasm and the nucleus is towards one side. So, this, these are the features of, uh, dysplastic plasma cells. Like this one has a central nucleus, but there is still a halo present over here. The scenario, think about the scenario as well. The scenario does not go with hairy cell leukemia. The hairy cell leukemia usually has pancytopenia features.
Sir, there is one question. I have one question, that when we see this plasma cell dyscrasia on peripheral smear and the most likely or most, uh, suggestive diagnosis is plasma cell leukemia, do we go for serum protein electrophoresis and beta-2 microglobulin? If they ask, don't. If they ask you in the next question, what investigations are required, then you have to mention. Sir, thank you, sir. And secondly, the examiners have a key. Examiners have a key according to which you have to answer the question. Now, this patient has H Jolly here as well. You have to mention Jolly in your answer as well. Right. So you have reported the blood film. The next question is, what are the, uh, prognostic markers in a patient with plasma cell dyscrasia?
Um, sir, prognostic markers include, uh, serum LDH, beta-2 microglobulin, and the cytogenetics. And, um, and, uh, and serum albumin as well. Albumin as well. And, and, um, um, LDH and, um, plasma cell percentage. If it is more than 5%, you call it as, uh, plasma cell leukemia, and it is a high-risk multiple myeloma. It is called high-risk multiple myeloma as well. And its treatment is a bit different, but mostly most of the patients are treated according to the same line of therapy as multiple myeloma. But there is a new guideline regarding multi, um, regarding, um, plasma cell leukemia or high-risk, uh, multiple myeloma in 2024. They were published in July 2024, and they have, uh, suggested some new regimens to treat plasma cell leukemia. If you have heard about Optimum, uh, study or concept study, they have suggestion of different quadruple regimens for plasma cell leukemia. But we are not currently using it because they are not NICE approved. We are still, um, using, um, multiple myeloma guidelines for the treatment, transplant eligible or ineligible, or, um, the DT past therapy for plasma cell leukemia.
Now, next question is, what is the expected flow cytometry in this patient?
Um, sir, these cells would be CD38 positive, CD138 positive, and, uh, CD19 negative. And, uh, uh, CD56 might be positive as well. Why CD56 will be positive here? Aberrant expression. CD56 is an adhesion molecule. If it is negative, it will allow the plasma cells to come into the peripheral blood. If it is positive, the plasma cells will stay inside the bone marrow. That's why in multiple myeloma, you do not see many plasma cells in the peripheral blood. But in plasma cell leukemia, you do see, uh, plasma cells in the peripheral blood, as this case. So, plasma, so CD, so CD56 is negative in plasma cell leukemia. It is positive in multiple myeloma. Okay, sir. Thank you, sir.
And do you think this patient is transplant eligible or transplant not eligible?
So, the patient is an elderly and most probably he would be having comorbidities. He has comorbidities. Do not say in the exam, "most commonly he would have comorbidities." It has a negative impression. They have mentioned in a scenario that the patient has cardiopathy and nephropathy and he is 80 years old. So, keeping in view the comorbidities and his age, uh, he is transplant ineligible. Yeah, so you will select a, a therapy for him in the category of transplant non-eligible patient.
All right, so plasma cell leukemia is usually a short case in the exam, but it can come as a long case in the exam as well. Be ready for that because it has new guidelines, so it can appear in both part one and part two.
Uh, sir, I want to ask a question. How often, uh, you use, uh, CAR T-cell therapy for multiple myeloma? Is it approved or not approved yet in UK?
Uh, it, it is approved, but it is usually an MDT decision. The patient assessment. Okay, sir. Thank you. But it is not first line.
All right, so this is the second case. This is a 52-year-old man who is very unwell, presented to the emergency department with, uh, worsening fatigue. On examination, he has lymphadenopathy and abdominal discomfort as well, which is because of the splenomegaly. He has lost, uh, 10 kg of weight in the last 6 months and he is short of breath as well. Chest X-ray shows pleural effusion. The full blood count shows hemoglobin of 98, white cell count of 58, and platelet count of 130. The biomedical scientist is concerned that this can be a leukemia. Any volunteer for this case?
Um, sir, um, can you give me a low, uh, sorry, a high power view as well? I want to see the morphology of white cells. Okay. Okay. All right, so I will move it slowly. Okay.
Uh, sir, this is a peripheral smear of a patient, uh, showing, uh, normocytic, normochromic red blood cells and, um, uh, there is, uh, sir, um, mhm. Okay. Uh, sir, there is, uh, marked, marked leukocytosis, having atypical lymphoid cells with cleaved nuclei, cleaved or clefted, uh, you can say, uh, clefted nuclei and, uh, smudging. Smudging is also seen. And, uh, some of the cells are very bizarre shaped. And also we can appreciate the presence of nucleated red blood cells. And, um, um, yeah, it might be a follicular lymphoma or, no, that is too early to say. It might be some lymphoproliferative disorder.
I want you to report the blood film for the exam purpose. Okay. Okay. Um, the peripheral smear shows normocytic, normochromic red blood cells and the white blood cells are increased. And, uh, there are also nucleated red blood cells seen. And, uh, these, uh, the white blood cells, they show the clefted, uh, nuclei and smudged cells are also seen. And, uh, some of the atypical, uh, white blood cells are medium to large size, having open nuclear chromatin and, uh, prominent nuclear eye, which we, uh, are probably the blast cells. And I also appreciated a few eosinophils as well.
What is your impression?
Um, so my impression is, um, of some, uh, lymphoproliferative disorder. And, um, um, and I would, uh, recommend, uh, flow cytometry and bone marrow aspiration and biopsy. Right. And I will also go for corrected white cell count because I have seen, uh, many nucleated red blood cells.
Can I have a go? Yes. Answer the question. Report the blood film.
Yeah, so, um, the white blood cells show, um, um, predominantly lymphoid cells with monomorphic appearance with some of the lymphocytes showing clefted, clefted lymphocytes, clefted lymphocytes. The, uh, there is presence of nucleated red blood cells. The red cells are appearing, there is some degree of anisocytosis, at least that's what I am getting. Occasionally I can see a few spherocytes and some rouleaux formation, at least from the screen I can see there are few rouleaux formation. Platelets are reduced in number, consistent with count. Impression, I would say this, um, the blood film is suggestive of a lymphoproliferative disorder. Would suggest, uh, urgent hematology referral. Further investigations which would include, uh, peripheral blood for flow cytometry, bone marrow biopsy, and further investigations to rule out, um, um, further investigations of the CT scans. That's what I would say. I forgot to mention smudged cells in between. My apologies.
Yeah, so the blood film shows leukocytosis because this is the dominant feature. I always mention dominant feature first. Some of the, uh, white cells are small to intermediate size with mature chromatin having a deep, uh, cleft. Some of them are large with a prominent nuclear line. Previously, they used to be called as centroblasts, but that category has been removed after WHO 2022. The red blood cells shows mild degree of anisocytosis with few rouleaux formation. The platelet count is decreased, but no, no clumps seen. The blood film is consistent with lymphoproliferative disorder. The patient needs further investigation like flow cytometry, bone marrow biopsy due to cytopenias, and CT imaging for any lymph node biopsy if present. So that would complete your, um, your report for six months. Obviously, you cannot make a diagnosis on the basis of blood film. They would give you some flow, or they, or if the diagnosis is obvious, like in the previous case, then they would ask you what is the expected flow cytometry.
So, the flow cytometry of this patient comes out to be CD5 negative, CD43 negative, CD19 positive, CD20 positive, and immunohistochemistry shows BCL2 positive as well. So, what are your thoughts about the diagnosis? Can you please repeat the flow cytometry? CD5 positive, sorry, CD5 negative, CD43 negative, CD19 positive, CD20 positive, BCL2 positive, and CD10 positive. It can be, sir. This is follicular lymphoma. Consistent with follicular lymphoma.
Okay, so the flow is consistent with follicular lymphoma. What is the final diagnosis?
Follicular lymphoma in leukemic phase. In leukemic phase. Yeah. So, do not confuse follicular lymphoma in leukemic phase with high-grade lymphoma because the high-grade lymphoma has a separate morphology as compared to follicular lymphoma. If it, if it was DLBCL, you will see a lot of big cells with vacuoles in it. We had seen DLBCL blood film before, right? So, this is the final diagnosis is follicular lymphoma in leukemic phase. These small to mature, uh, small to intermediate size lymphocytes, they are the features of follicular lymphoma. And you can see this cleft, which is present from one end to another end. This is the feature of follicular lymphoma.
All right, um, would you treat? Sorry, I'm interrupting you. If, first, I am saying there are RBC inclusions. Are these iron or artifacts or platelets? I mean, are these Howell-Jolly bodies inside? Or are we? There is a small dot near this. This one is a Howell-Jolly, and this one, because we mentioned in a scenario, the patient has abdominal discomfort with splenomegaly, so he must have hyposplenism. So that can lead to Howell-Jolly formation. Yes, yes. You have to mention all the findings that are present in the blood film because the person who checks the paper may not be a clinical hematologist or may not be a morphologist. He only has a key which he has to select whether this candidate has mentioned Howell-Jolly? Yes. One more. Nucleated red blood cell mention? Yes. One mark. Leukocytosis with cleft mention? Yes. One mark. So you have to mention everything that is present in the blood film. Like in the previous session, we had a sickle cell crisis blood film, and the question was, name six findings in this blood. It means there are six findings in this blood, right?
So the last question for this short case would be, would you treat this patient?
Yes, uh, we would treat this patient because he has entered the leukemic phase. Mhm. He has cytopenias and he has put infusions as well. Yes. And you will be doing imaging for this patient. In follicular lymphoma, we usually worry for compression of any, uh, nerves or arteries because the follicular lymphoma has a tendency to be present around paravascular lymph nodes as well, where they usually press the, uh, nerves and arteries or veins. So you may be seeing a patient in your hospital where the disease burden is less, but they have some lymph node somewhere in the body is compromising other structures. That's why we decide to treat follicular lymphoma as well. Otherwise, if they are asymptomatic but diagnosed as follicular lymphoma, they are usually on watch and wait list.
And what is the criteria? Name of the criteria that is used to decide whether the patient needs treatment or not? The prognostic score. It is a GELF criteria that is mentioned in the BSH guidelines, which you use to decide whether the patient needs treatment or not. Sir, can you please repeat the name? GELF. GELF. Okay, sir. Right, thank you.
Follicular lymphoma can be a short case in the exam or it can be a long case in the exam as well, where a follicular blood film would be given and then the patient would present again after a few months with cytopenias, and then the bone marrow trephine would be given to you. Bone marrow trephine of follicular lymphoma has a specific feature of paravascular infiltration, and later in the question, they would ask you that this patient has now converted to, uh, high-grade lymphoma. So, follicular lymphoma is important for both, uh, short case of morphology and long case of morphology.
All right, the third case. So this is a GP blood sample referred to the district hospital where you are working because of eosinophilia. The patient's white cell, full blood count shows hemoglobin of 110, white cell count of 11, but the eosinophil count is three, and platelet count is 190. Who wants to have a go? Anyone from clinical hematology background or from, uh, non-hematology? Mary, yes. Mary, he, um.
So, I think with an eosinophilia film, I'd want to look around on the lowest power possible for a while to look for parasites first. Right. So this is power four, and I will move around the blood film to see if there is any parasite or not. So whenever you face eosinophilia in the exam, always go to power four to see for any, uh, parasite. Oh, there we are. Yeah, so we've got, we've got a few worms because this is a Nias film. They are very generous to give you a lot of parasites. But in the exam, you may struggle to find one. So better have a good look of the center of the sides of the slides in the exam. So this is the parasite. I will make it to 10 now to see further features of this parasite. This is power 10. So we've got a sheathed worm, or, um, microfilaria that I, I was get confused about that. Sorry. Which has got the presence, you can see the sheath, um, extending beyond the head end. So I just want to see whether the nuclei go all the way to the end of the tail. Yeah, so now it should be clear. Yeah, so there's, you can see the sheath. It doesn't look like the nuclei go all the way to the end of the tail, which would be most in keeping with a Wuchereria. Okay, so let's see another, um, one. If, if there is any Wuchereria one that would be helpful. Is this a, can I just ask, is this a Giemsa stain or is this a normal? It's a normal stain. Normal stain. That's what I thought. So, so it should be bluer if it's Giemsa. So, yeah, maybe this one. Oh, so in this one, it looks like the nuclei do extend all the way to the tip of the tail. Yes. Now, hopefully, we will be able to. So that would be in keeping with a Wuchereria. Yes. So this is the sheath. Is the head end? This is again the sheath and this is the tail end. They are coming in the line here. Okay.
So how would you report this film for the exam purpose?
So I'd report it as, um, the dominant findings are the presence of, um, microfilariae which are sheathed and demonstrate nuclei to the tip of the tail in keeping with Wuchereria. And then I would comment on red cell morphology being, um, unremarkable as, uh, you know, there are increased numbers of morphologically normal eosinophils. Um, mature neutrophils and lymphocytes which show no significant abnormality and adequate numbers of platelets. Yes, I'm searching for any filarial worm. The filarial worm is usually better. This is the one. Oh, yeah. That's, don't normally get the sheath that well stained, as I mentioned. This is a Nias film. Yeah, you will see a lot of worms in the Nias films and also they will be looking better as well as compared to the exam one. Yeah, our exam has only one one per slide. They're very stingy with their worms in the exam.
All right, so for the purpose of the audience, do you know any that you have remembered to differentiate between different worms? Wuchereria, Loa loa, or Brugia malayi?
So the first thing is to look and see whether they are sheathed or unsheathed. And then the distribution of the nuclei. Um, so Loa loa is the one that classically has the nuclei all the way to the very end of the tail, whereas the Wuchereria, I think it is, they don't normally go all the way down. Um, but the Loa loa is also sheathed. And then I think the, um, Brugia malayi are not sheathed. Is that correct? Yes. And another one is Brugia malayi. I don't know whether I'm pronouncing the name correctly or not, but they are also sheathed, but they have only two nuclei at the end of the tail. Yes. So I had remembered like that. Wuchereria starting from W, VM is empty. Wuchereria tail is empty. Brugia malayi has bi-nuclei at the tail tip of the end. And Loa loa, Loa loa goes to the lower end, so nuclei extend to the tail. Like that, I had remembered for the exam purpose. And Mansonella, Mansonella has no sheath. Um, yeah.
And do you remember any treatment drug for this Loa loa?
You can either use mebendazole or albendazole. The book has mentioned diethylcarbamazine and other sessions and courses also mention DEC for the treatment of, uh, Loa loa or loiasis. So it will be either an eosinophilia case in the exam or someone, uh, who has recently traveled to Africa and came with a red swollen eye, which is called Calabar eye or Calabar swelling. But in case of eosinophilia, always go to power four to find out if there is any worm or no. Look thoroughly because we suffered in the recent exam because of this. Right, so this was the case. Thank you, Mary. Thank you.
So this is the fourth case. This is again a GP blood sample of a 5-year-old boy who recently immigrated to UK from an Asian country. A full blood count reads hemoglobin of 128, white cell count of 8, and platelet count of 180. Any volunteer to comment on the blood film?
Uh, sorry, sir. Can you please repeat the presenting complaint of this patient? So this is a GP blood sample of a 5-year-old boy who has recently immigrated from an Asian country. The, uh, full blood count shows white cell count of 8, hemoglobin of 128, and platelet of 180. Okay. So this is power 10 to give a general overview. So power 50, there is marked ectocytosis seen in the red blood cells. Okay.
So for the purpose of the audience, why this is not a boat-shaped cell or why this is not a sickle cell? The sickle cells, uh, will be having both tapering ends and these are rounded on sides. And, sir, history of the patient is not suggestive. Shape, you are talking about the elroy. Still carry, uh, halo. The red cell halo is still present in them, and they are elongated or oval shaped, but they, they carry halo in themselves. The sickle cells are, uh, HES, they don't have any halo in in the sickle cell, and their ends are sharp. So this is the difference between elongated or oval shaped cell halo and the edges of the cell. All right, so I want you to report this film for the exam purpose, six marks. Anyone?
Yes, I can try. Yes, go ahead, please. So, uh, the peripheral smear shows, uh, RBCs. There is marked anisopoikilocytosis, but majority of the red cells are elliptocytes in shape. And, uh, as far as I'm seeing, there is no inclusion in the red cells. No, sorry. Red cell inclusions inside the red cells. And platelets are adequate and there is a few, uh, schistocytes as well, but there are few in the background. And, uh, majority of the population. Yeah, this is Howell-Jolly body. Okay, so you have to write all the findings for the exam. Do not ignore any finding. And platelets are adequate in the background. And neutrophils are preserved. And platelet count is adequate in the smear. So the peripheral blood, peripheral blood is consistent with any hereditary membrane defect. Most likely, hereditary elliptocytosis. Do not say hereditary elliptocytosis, okay? Only elliptocytosis because you do not know the history of the patient. This is only blood film in front of you. So do not make such mistakes in the exam.
So this is the only blood film. That this blood film shows, red are anisopoikilocytosis. Most of them are, uh, elongated to elongated to oval shaped elliptocytes. If you want to explain, we just add one more line that the elliptocyte is carrying, uh, red cell halo. The ends are not sharp. Just for the purpose of other audience, as I'm mentioning this. The platelet counts are fine. White cell count is normal. Most likely, uh, associated with elliptocytosis or membrane, like ectocytosis. The patient needs further investigations to rule out the cause of elliptocytosis because the elliptocytosis can be because of multiple causes. It can be hereditary, it can be iron deficiency anemia, it can be myelodysplasia, or hematinic deficiency. Even they, they can lead to, uh, elliptocytosis.
So the next question would be, what is the defect in hereditary elliptocytosis and what is the inheritance?
Inheritance, I'm not confirmed. Maybe autosomal, uh, recessive. It's dominant. Autosomal dominant. And where is the defect in the membrane in elliptocytosis? No, I don't want to remember. Defect. Defect of spectrin A and, uh, alpha and beta spectrin. Yes, you can mention spectrin alpha, beta, and protein 4.1 defect in the, uh, hereditary elliptocytosis. The hereditary spherocytosis carries protein 4.2 defect. And this one carries protein 4.1 defect. This is for part one question, but they can ask in the, uh, part two as well as a one mark or two mark question in a short case.
All right, what is the management of this patient if it comes out as hereditary elliptocytosis?
Supportive treatment, uh, like, but here's HP is, uh, is 12. I think, sorry. No treatment. I think, I think no treatment is there because hemoglobin is normal. Hemoglobin is 12, as far as I remember. Yeah, so if the patient is asymptomatic, no treatment is required for hereditary elliptocytosis. But if he becomes anemic, then he would need folic acid replacement for that. Yes.
What is the result of EMA in hereditary elliptocytosis? The last question.
You are talking about fluorescence EMA? Yes. No, fluorescence. Yes. You see many membrane binding assays or binding tests? Sir, there is decreased EMA binding. So EMA remains normal in hereditary elliptocytosis. Is it low in hereditary spherocytosis? Okay, yeah. So remember this if they ask you in the exam, uh, both for part one and part two. Right. Thank you.
So, blood, any type of blood films can come in the exam. You can have iron deficiency anemia. You can have, uh, B12 deficiency blood film in the exam as well. In short cases, we had these, these type of things in the recent exam. So the films may look very easy to you, like this is elliptocytosis, okay, fine. But the trick is in getting marks in such cases. You should at least get eight out of 10 marks or nine out of 10 marks. Each number, each mark in the exam matters. If you talk to your, uh, two colleagues, they would tell you the importance of five to one mark. So please do not ignore anything in the blood, even if you know that you are good in morphology. Practice them frequently with, with yourself, with your colleagues, with your senior in the hospital, so that they are on your fingertips and you should know what is expected in a blood film.
So this is the last blood film of the day. Ignore this stuff. This is just a particle in oil which is moving. This is not a live bacteria or virus, anything. Right. So this is a 29-year-old patient who presented to GP because of the, uh, lower respiratory tract infection. So he was given, uh, Lexine tablets or antibiotics to take. On the next day, he became very short of breath, pale, and on repeat blood test, he was found to be anemic. Hemoglobin dropped from 130 to, uh, 85. The biomedical scientist alerted you because, uh, he thinks that this patient has a TTP. He has noticed schistocytes in that in that blood film.
All right, anyone want to go with this film? Please. Seems like it has a spherocytosis. Right. So this is power 10. Sorry, who was that? You want to comment on the blood and report the blood? Anyone? I can try. If no one else wants. Okay, go ahead.
Right, this is power 50 now. You heard the story. A young man who has taken Lexine for lower respiratory tract infection, presented to ED next day because of shortness of breath, and the biomedical scientist alerted you for the presence of schistocytes. So this is the blood film. Well, I can see spherocytes as well as ectocytosis in the red cells, but there's also a bite cell. Is there? Yeah, few cells are looking like, uh, yeah, this is a bite cell, blister cell. And bite cells. Mhm. And, uh, and the platelet count is adequate in the background. And there is maybe Howell-Jolly bodies in the. Yes, some of the red cells have Howell-Jolly bodies. Neutrophils are preserved and platelet count is adequate in the smear. So the peripheral blood, peripheral blood is consistent with some, uh, enzymopathy disorder or maybe that is enzymopathy on the basis of blood film and history. So we can say oxidative stress. So the patient has oxidative stress because he has taken Lexine and then he developed hemolysis. There is also polychromasia. Some polychromatophilic cells are seen. Yes. And even the neutrophils are hypergranular as well.
So how would you report this blood film for the exam purpose? Six marks.
I would, uh, so there's hypers segmentation as well in the neutrophils with hyper, yes, granulation. These few neutrophils show very high hypers segmentation, toxic granulation, and cytoplasm vacuolations are also appreciated.
So how would you report that film for the exam purpose?
So the peripheral blood, uh, consistent with, as Dr. Habba said, that oxidative stress under the oxidative stress of every, most, second to the enzymopathy. So I would go for further investigation or refer to the hematologist.
So why are you saying enzymopathy again and again when I don't know? Because he, and because hemolysis can be related to B12 deficiency as well. This patient has hypersensitive neutrophils. So there can be multiple causes of hemolysis in this patient. So the, so the blood, but why there are bite and blister cells and why there is Howell-Jolly bodies inside the cell? But this is not a feature of megaloblastic anemia. Yeah, so there can be dual pathology as well. Other thing, other thing, actually, this is an acute drop in hemoglobin from 13 to 8. This is a hemolytic process after oxidative stress. And these bite and blister cells are very obvious in the peripheral field. This is my own. Although there are hypersensitive neutrophils are also there, polychromatic cells, bite and blister cells are very obvious in the peripheral field. That's the reason I think maybe more likely this is an enzymatic process due to oxidative stress and enzymopathy is one of the cause, underlying cause. Yes, yes.
So, um, can I, sorry, can I try and report the film? It might not be amazing, but I think I would term it as, um, um, prominent anisopoikilocytosis, uh, with prominent bite and blister cells, mild polychromasia, Howell-Jolly bodies, and, um, target cells are also visible. Neutrophils show toxic segmentation, toxic granulation, and hypers segmentation. Vacuolation is also seen. Uh, I actually don't remember what the platelet count was, but, uh, slightly reduced. And I would say, um, differentials would be, um, um, oxidative stress leading to oxidative hemolysis, um, and a possibility of a hematinic deficiency as well.
And what would you suggest?
I would suggest, um, urgent hematology opinion. Not urgent, but like, discuss with hematology. You are the, you are the hematologist, right? Yes. Okay. Um, so a complete hemolysis screen, and checking for hematinics, B12, folate. And I would say do a G6PD assay, but once the patient's out of the acute phase. Yes.
So, as you mentioned, all the features of the, uh, blood film, you have to mention. This blood film is an audio blood film to come in exam. Mention six features in this blood film. This patient has all the features of hemolysis and it has bite cells, Howell-Jolly bodies, spherocytes, polychromatophilic cells, hypersensitive neutrophils, and the, and the few target cells and granulated neutrophils as well. Most likely consistent with hemolysis secondary to oxidative stress and hematinic deficiency. The patient needs, um, blood for hematinics and stopping the precipitating factor, if any, which is Lexine in this case. You can mention G6PD as well, but we all know that you cannot check G6PD in an acute hemolysis. That should be done once the acute hemolysis is over. And, and if the patient has blood transfusion, then you have to send blood for PCR or sequencing if indicated. Otherwise, you have to wait for 3 months.
All right, now the next question would be, um, what are the causes of false negative or what are the conditions that interfere with G6PD assays? These can be pre-analytic and analytic causes and type of screening assay, temperature, I mean, it depends upon the screening type of, uh, assay. So pre-analytic, like hemolysis and so if there is polychromasia, reticulocytosis, reticulocytes have a lot of G6PD enzyme, you get false negative results. Normal G6PD levels during acute hemolysis also. Recent also recent transfusion. Yes, if you have done blood transfusion for your patient, that would affect your G6PD testing as well. If you have, um, um, if the patient is grossly anemic or if because of the infection, there is significant.
Right, please name the G6PD assays for male and female patients. Two marks. They are given in the guideline. There's a figure in the guidelines in the BSH which has mentioned G6PD testing for male and female patients. Although it is X-linked, but you can get very rarely G6PD deficiency in females as well. Well, female need, yeah. Continue, Dr. Sindhu. For female, female needs a quantitative assay, is a confirmatory assay, because screening assay produces false negative. And, uh, while we can go for the, uh, screening assay or qualitative screening test for the male, like fluorescent spot and, uh, decolorization test for the male. And for the female are the quantitative assays, which are called Glo-Magline test or one substrate assay. If they are equivocal, then you go for confirmatory test. There is a figure given in the, in the BSH guidelines in G6PD guidelines. If you remember the names, that is fine. They can ask you in the, uh, in the short case in morphology, so you should not lose these marks. Okay. All right, so this was the end of morphology Session 8. We will see you again next week. These sessions are free, but if you want to donate, you can donate either on this account or in this account, or I will share a coffee link in the, um, group. You can donate over there. Please share, subscribe, and share our channel. Thank you and have a nice Sunday. Thank you.
Uh, sir, I have a question. That, uh, what is the final time for the