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. Def. Neutrophilia, thrombocytosis. What is the HP? HP is 99. We go to higher power to see the cell target cells. So how a lab person will report it? Let's see a few more sections and then neutro with rosis. Query, uh, success. It's plet antos. You know, one or two spherites about too. I think the neutro is showing toxic granulation also. Yes, there is thick granulation in the neutro. 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 hypes segmented. What is B12? 8. B12 was normal, but the 8 was low. Three less than four is L in this neutro. I think you just skip from is 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 neutro in sepes as well. So I will make this little feel big to see if these are death crystals or sh. No, think this is just the shadow of the RBC behind it. I was thinking maybe these are the death crystal that that are present in the severe sees. That's S L stage though, isn't it? M. It's not a good sign. Organ failure then? Yeah, if there is multiorgan failure, then these death pistols do appear. Uh, one more hypers segmented neutro. Fate deficiency. The patient had low FID. We thought that segmentation is because of the low FID. This patient culation screen was abnormal as well. So what was the fibrogen? The CL CLA 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 receptors or infection. And if it is one only, then that is low as well. This patient is in DIC because of the abnormal culation 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. 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 FED count will be high because of the in infection as a reactive response. The V cell count will be high, but it will be mostly either nutrifil or band form. Sometimes Milo side do appear, but not always. And you need to check the culation 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 bar 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 of the DIC, it might be more trosy penic. In DC, 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 spitted count is high. Yeah, but as a as a response to infection, the pled counts goes high always. But if it is a virus thing, virus always suppress your bone marrow and the there isto. One fragment is there. Just no. So you will report the blood f for the exam purpose that this this Blood Fame contain leucocytosis and thrombocytosis. There are multiple shites in the blood. No blast. Multiple uh toxic granulation in the nutro. Multiple toxic granulated nutrifil and band forms in there ised anos cytosis. The uh impression is likely uh reactive response to infection. Please correlate clinically or check the infection marker and culation screen for the thing. That's about it. Yeah. So normally, 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 the plastic picture. I think this is CML. It's a different. There is left shift. There is meites. Meoc band. So this one is a neutr. This is a band form. This is a Milos. There is a dip here. It can metamylocyte. 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 see any uh pH of nrbc of the high B activity and looking for B. I see one there now. Yeah, this one looks like EOP. Orange gran. And in this [Music] one there, there's 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 loost. This one well. So they can ask you in the exam, the difference between a CML and LIC picture in the. So you have seen the previous blood f whose white cell count was high and this Blood F whose white cell count is high as well. There is you basilia and whole myeloid peak, which you which you didn't see in the uh septic picture of blood f. And the basophil is the main differentiating point between uh myeloid reaction and the uh CML. Why are there more Bas of LC than CML? The 922 translocation and mutation result in formation of all myeloid peak, including basophil, eosinophil as well. H. This the only explanation. So how will you report this Blood f? Um, can we see a aside just to compare with the the size of uh RBC? Lymphocyte? It would be very difficult because the film is full of my peak. Uh, maybe this one is 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 Le neutrophilia or leyocytosis with the bands, metamylocytes, myelocytes. I think the blast should be uh noted as well. Yes, the blood contain liosis. There are multiple neutro, band form, metamylocytes, myelocytes, promyelocyte, blast form, multiple nrbc along with basophils and EOP. Creed count is slightly increased. Red cells are normal. The blood film picture is consistent with uh most variable diagnosis of chronic myeloid leukemia or you can say it is most likely a bio proliferative 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, what are the poor prognostic factors in CML? What are the prognostic tools in CML? And we have soal. Yeah, tool. AOS. Utos. Yeah, 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 root 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 Fe remission that we discussed in our yesterday s. 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 nickos folder, but it do come either in the W or in short question in the in the part exam. So you have 9 minutes in the short question and in these done 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. Count of 380. Poli. 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. M is probably high too, the looks of it. Hct above 49 in female and 52 in male. The one clue is that that they will give you f BC 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 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 looks 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 cell. That can be quite misleading because you could think it be ruler because that's another term for stacking of coins. The ru. 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 looks 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 St? I certainly requested Jack too. If I say no, I don't want to request Jack to, there is something else that you need to do. I examine the patient for Meg. Why suggestive of MPN? So whenever the counts are high, do not jump to ens 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. Osa. Yes, the patient may be very obese, may be having um sleep apnea, smoking, taking steroid for gin, maybe having a COPD or any known solid organ cancer secreting a lot of arthropo. 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 EPO level of this patient. If the EPO level is low and cell count is high, it means there is some malignant element is involved. If the EPO 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 J2. So if you jump directly to uh MPN panel or J2 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 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 specialities, 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 definition? 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 copy or mediastinal. So this is a quite large lymphocyte, but it has a bopic cytoplasm and it is coping this RBC. And this is a mature one. And there is no blast in it. What is the lymph 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. Is basophilic? There is no nucleoli. No nucleoli in this cell. And these are the features of reactive lymphocytosis. So what test you will do to confirm your diagnosis? Blood test. Why to exclude what what probably? Sorry, exclude what? Usually we use the flow. Exclude CL or we can. Yeah, other markers also for the uh B cell. BL does not appear like this. CL has a 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 CL counts are always about 20. Extreme cases are in 300, 400 as well. And CL doesn't happen in 24-year-old child. Sorry, patient. This is reactive lymphocytosis. I was thinking about EBV infection. Yeah, Monospot test. Monospot test. Yeah. Yes. And to exclude other infection, you will send HIV serology, Hepatitis B and C. What's the CRP like? CRP were 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 typical coping here. Coping here. This one and that one. And the history matches uh infectious mononucleosis as for. 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 four aspirate. Trine and suspected blood film of a worm. You need to see on power four first for aspirate to see whether there is any particle or not. The warm, the warm blood film, you will see the warm on power four first. And trine at power four will tell you the cellularity of the. 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 neutro. There is myeloid maturation is present. These are few side. But is this cell? This one, this that those are nuclear RBC. And this is plasma cell. They make it big for you. This was a s that I was talking to. This this is a one-sided nucleus cytoplasm and a hell of here. This the plasma. That's a plasma cell. It's get the egg shape. Right. Egg. Quite a lot here. This one. These one are distic plasma cells with two nucleus. These are all plasma cells. This patient had uh 40% of the plasma cells in the bone marrow and the craft feature was was positive. CB me, um, calcium was high, renal functions were abnormal, anemia was there, and there were five lytic regions on the uh low do full body CT scan. And the paraproteins were IG 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 p first was a bit low. Sorry, am. 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 Wens room, but the book have mentioned flame shaped cells in IG. But I, yeah, but I have seen most of them in the Wens room, bone marrow, not in any other. Like these are plasma cells, but this is not flame shape. Only these few projections here, but I will not call it 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 term of li like this one has many projection on the top left. Both these. Yeah, it looks more of flame shape. Yeah, sorry. I don't have the trine of this patient because bringing out refine 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 joined plasma cells with eccentric nucleus with halo. Pro. Now there, these cells have sub Vu inside the inside them. This one and this one. There was a time used for these cells. Bodies or something like that, but I forget. Yeah, 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 Wens stor, uh, not commonly seen in multiple myeloma patient. 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. Thank you. Appreciate. Bye. Thank you. Thank you.