Transcription
Let's start our next session. Sorry for the delay. Uh, as I cannot see the team's screen, so if anyone wants to join, please let them in. Okay, so this is the first case, a very common case in our routine setup, um, very frequent. So this is a 30-year-old patient who presented to the emergency department because of weakness and tiredness, or say weakness and tiredness. And he has some uh infection symptoms as well. Like the emergency department have done a full blood count. The full blood count shows hemoglobin of 90, platelet count of 900, and white cell count of nine. So this is power 10. Just a general overview of this slide. Is there any volunteer who can start commenting on the blood frame? The blood frame will go to the lab first. Definitely, thrombocytosis could be reactive. So we'll move to power 50. The oil.
Yeah, so you can see heightened here, whole body here, and this one as well. Infection. I thought it'd be more neutrophils. And this C, this he has many SCS in the blood. An autoimmune. So how would you report it from the lab? I certainly say mark thrombocytosis, um, spites, target cells, and you have seen how Jolly bodies as well. Quer hyposplenism. I'm seeing enough, really looking around because hyposplenism is also one of the causes of um thrombocytosis. Not too sure is it HS or not. Usually from the from the lab, uh, we get a report that mark thrombocytosis, exclude secondary causes of thrombocytosis. If still any concern, discuss with clinical hematology. Yeah, that's about right. Yeah. So this is the standard report that we receive from the uh, lab.
Is there any clinical hematologist who want to comment on this blood thing or to report it for the example? There is no clinical hematologist with us today. Sorry, sorry. I just joined in. Uh, sorry, I forgot. I couldn't find the link, so I just joined in. Can you just repeat me the contacts? I'll report it. There is this is a 30-year-old young man presented to the emergency department with worsening fatigue and tiredness. He has some sore throat like symptoms as well, and he has blood tests done, which shows hemoglobin of 90, platelet count of 900, and white cell count of nine. The the blood is the blood film is first reported by the BMS or the lab hematologist, and he he made a comment that the blood shows more thrombocytosis, exclude secondary causes. If any concern, contact clinical hematology.
Okay, so so what I can see from the picture that you have on the slide, there are a couple of spherocytes. There is thrombocytosis. There are some target cells. Um, if you can scroll around a bit. Yeah. TS definitely. What's the R? Like R count is 60. Yeah, okay. It's okay. I'm just trying. So I do see some platelets here. There's a mark thrombocytosis, myocytocosis. See Lefty like. Is he is spherocytosis doesn't add up to the picture, to be very honest. They had lots of target cells there. Looks like at least from what I can understand, looks like a giant platelet somewhere. Yeah, they are giant platelets in there. They are giant platelets in there. And, um, did we see a, um, is is the DCT and bilirubin? What, what are they like? The DCT was negative and B liver function test is normal. So then this is thrombocytosis until proven otherwise. So, um, in the context of an infection or a viral. So so what I would suggest is is three things. First, I will say this is this is, um, this is thrombocytosis. There are few, there are spherocytes in there. And and in the context of the history of viral infection, I would say that first, two hematinics, B12, folate, um, rule out infection. If thrombocytosis persists, there's no other lines dropping apart from anemia. Um, so, um, I I would think I would say that this first off, start with the basics. Start with the infection screen and viral and hematinics and whatnot. And then if all of the context, it doesn't clear out and if the thrombocytosis persists with anemia, then we can we can look at hematology review. But at the moment, I wouldn't recommend any hematology review for that matter. But yes, the spherocytes do look, doesn't not fit the profile. But other than that, the the it is it is it is just mark hocytosis in in a patient with viral infection, not not something that I would be interested.
Can spherocytes appear with bleeding? Yes, they can. They definitely can. But this patient, the history you're giving is of a viral infection, isn't it? Yeah. So you need to make a report in which you have to mention the findings and you will give some suggestions to them what to do next. So what I would suggest is number one. So I'll mention what I saw. So I saw spherocytes, I saw target cells, I saw thrombocytosis. Um, white blood cell count. I the white blood cells look all rightish. I think it looks like a, yeah, they look all rightish. Yeah. So so neutrophils do look fine. I would suggest hematinics next. Look, screen for bleeding, viral infections. I I would say look for causes of, um, to rule out bleeding in viral infections. Um, sent for hematinics, DCT, liver screen, what you do profile in this patient. Yes, they are target cells definitely because include iron and B12 and folate because they would think that the doctor has mentioned hematinics. So let's do folic acid and B12 including. I would usually I write hematinics including iron, B12, folate, the full package. Yeah. The blood film contains thrombocytosis. There are multiple target cells. We have seen few how is initially as well, and I think this is another one. Yeah, yes, I can see it. The the plate has an isos as well. There's no trauma history, right? There's no trauma history. Patient came in with viral symptoms, isn't it? Yes. No trauma history. No trauma history. So yeah, so in in the in in the context of the story, usually you tend to never find out until someone explicitly asks the question, is the patient had any splenectomy? So cool. Then you say that the impression is thrombocytosis, which can be primary and secondary. But first, we should rule out secondary causes by sending these these tests. Yeah. And you would certainly receive a call from the department that this patient has related count of 900. Should I give, should we refer it to hematology because this can be a proliferative? And I will, if I on the receiving end of it, I would say first rule out secondary, then we talk about it. This is secondary until proven otherwise. So reaction with given the history that there has tons of things now. If I, if I, you add a context of a how Jolly body in it, then this it could be secondary due to T of things. Now you have viral infection, you have probably bleeding, you probably also have in of course infection, inflammation, iron deficiency. You have a ton. You have a couple of things going on here which would add to the picture of um, of thrombocytosis. And the other question and which probably which have which I should have mentioned earlier is there any previous blood counts to compare? Because the idea behind primary thrombocytosis is persistence of thrombocytosis with a platelet count of more than 450, six weeks apart. So if that is the case, by all means we can think about it. But any thrombocytosis is secondary until proven otherwise. So I will say do this. If the if the if the thrombocytosis and thrombocytosis can take up to six weeks to resolve. So if the thrombocytosis persists despite correction of the above causes with no no splenectomy, no clear secondary, patient can be referred to hematology. But in the absence of secondary. Yeah. So I'm bringing up this case because this is a very common case in our hospitals where when the treated count is high, the lab or the treating team on hematology is this a Fed cancer or so. If there is thrombocytosis, we should always recommend exclude secondary causes. In UK, iron deficiency anemia and acute phase response is the commonest cause of thrombocytosis. In okay. If secondary causes are excluded, there is persistent drosis, then you can send JAK2 or MPL, MPN panel for this patient to exclude clonal thole. Do we I add may I add one thing? The M if someone has primary thrombocytosis, so even if the JAK2 is negative, it still doesn't rule out ET simply because that there are around, I think 25%, I'm quoting from my memory, 25% of patients could be triple negative. So a bone marrow is still required for a final rule out in even if your suspicion is high. But if the MPN panel is positive, it rules out nearly 70 to 80% of ETs. But 90% of the PBs. Am I am I right? Am I right? Yes. So you catch my question. My question was, do we need a bone marrow biopsy for that? But you have answered that because WHO says yes, and BSH says no. BSH says you should do bone biopsy only if the driver mutations are negative in triple negative. No worries. Thanks. Sorry, I became over the less in class. Apologies. No, it's okay. In FC exam, they will ask you to report the blood film, mention the secondary causes of thrombocytosis, and do we need a bone biopsy for this patient or not? Or they will give you the last question that this patient has been diagnosed with tal thrombocytosis. Now his St count is 1200 and he bled on that. But he is a young patient. What, what is the treatment now? Treatment options now? They can give you an acir, one, libron syndrome as a presenting case, complications of thrombocytosis are alone. Or they can ask you that this is a 30-year-old male with clonal thrombocytosis, only platelet is 900, but he his BMI is 35. He has hypertension and diabetes as well. Should we do start reduction or not?
Right, so this is a second case. This is a 21-year-old male patient who presented to the medical ASC because he has high fevers. He has noticed some lumps in the neck. So this is the general overview, power 10 of the blood film. Okay, this for the general overview. Do we have a volunteer to lucis? Seem to be a few monocytes about, I think. Okay, I will make it to power 10. Power 50. Make the things more clear. Looks the best. What P? Maybe the spleen count is low. So how the lab hematologist or biomedical scientist would report this? I say mark thopia. M. I need to see a bit more. Okay. Waits. He's coming with the swollen neck glands. Expect to see more lymphocytes or typical monocytes. M. I should add some oil to that. Um, what do you think about the nature of the lymphocytes? Smudged lymphocytes. The the one at 12:00 can be as smudged. But what about the other one? A smudged cell. What about this cell? Make it more clear. Let's see. Any thoughts about this one? This one. So obviously the lab person will refer this to clinical hematologist. But what usually they write? How they reported? And before referring to clinical hematologist, what is the lymphocyte count? Start count is 13. All right. Yeah. Looks a bit abnormal. Yes. So usually we receive this from the lab that there are atypical large lymphocytes in this patient. Looks like a lymphoma. Yeah. So refer urgently to clinical hematologist. They don't look atypical. So rule out, um, gland. I think this is the typical picture in front of you now. I should not move from this picture. And this is a common FC thought question appeared twice in the morphology cases in the last three exams. So we have mentioned previously, look at the patient and the symptoms. This this may give you some help in diagnosis. It looks as if it's quite reactive. It's molded around the red cells. It's typical shape. There's no clefts. I can't see clefts there. What is this phenomenon? Yeah, if they mold around the red cells, they're more reactive. This is called scalloping. This is the red cell scalloping by lymphocyte. There is no prominent eosinophils. They have a lot. They have a lot of cytoplasm. It is basophilic type. These are reactive lymphocytes. Patient is 19 years old and this is in common in the young age. And then you mention this patient has low platelet as well. Yes. It's just viral lymph, isn't it? Is a response to the viral infection? Yeah, probably infectious mononucleosis. Yeah, most likely infectious. Yeah. You need a monospot and an EBV test. EBV, ABV serology, mono test. We also do, um, hepatitis and HIV serology testing in these patients as well, just to other, yeah, diseases. So the candidates that will appear in FC exam, they must produce a slide like this from the lab. And because if it had not appeared in the last exam, it will for certain appear in the coming spring 2025 exam.
Now, the next case is the, um, 70-year-old male presented to the emergency department again with hardness and fatigue. All right. So this is power 10. There's mark lucytosis again. His platelet count is also low. Yeah, the proc is there. Let's go to 50 then. So do you think this is a blast? Oh, yeah, yeah. That's definitely a blast. Just see it more bigger. Need to see if there are any nuclear light there. Probably some blast. Could be an M1. This is another. We'll go to power 50 to see more cells. Not much granulation there. It is mild granulation. And when we look at this slide, first, this is a last week slide. We thought that they are there is a bit granulation. They are myeloid. But we get a different result. FL.
This film was rightly picked up by the lab hematologist. Yeah, straight into the consultant's office of this one. Yes. And he thought that this is an acute leukemia. H. So the cell markers, we agree with that. We thought that this is acute leukemia as well. We send the blood urgently for flow. This this blast has two nuclear. Nucleo my done. Yes. And and the flow that we get showed CD2 positive, cytoplasmic CD3 positive, CD5 positive, CD19 negative, 20 negative, and TDT was positive as well. So what was the count? What was the total count? It was 13. Another blast. We'll go to power again. Right. So I have told you the flow cytometry. What is the likely diagnosis? Looking for few more cells. S. I'm, can you repeat the flow again? Okay. Yes. So the flow is CD2 positive, CD3 positive, CD5 positive, cytoplasmic CD3 is positive, CD9 negative, 20 negative, 10 negative, TDT is positive. Thank you. Three prominent blasts in front of you. So what is the likely diagnosis on flow cytometry? Suggestive of T. Yeah. And how did you pick that it is a T? Just for the purpose of other people. The the B markers are negative, and the and the CD3 is positive. What are the B markers? CD19, CD20 are negative. Okay. CD9 and 20 are B markers, and they are negative. Correct. What are the T markers? CD3 and CD2. Uh, and I think TDT is positive, uh, as well. So CD2, CD3, CD5, they are T cell markers. Other T cell markers and other lymphomas. Uh, CD7 is also a T marker. TDT is a maturation marker. If it is, um, positive, it means the you are dealing with immature cell. If it is negative, it means the cells have matured and they have lost TDT. This is a T cell ALL. Do you think it has a good prognosis or bad prognosis? As compared to B prognosis? T cells have very poor prognosis, and we always struggle, um, with the treatment in such patients. Right. So what are other poor factors in T? This can be an question from still patient age, performance status, comorbidities. Yeah. So age more than 65 is considered as a poor risk factor. If the white cell count is about 100 in P, it is a poor. Hypo diploidy is a poor risk factor. Complex karyotype is a poor risk factor. In these patients, all right.
None of the consultant in hematology wants to come in their view. So this is another case. Is an 80-year-old female with persistent anemia and thrombocytopenia. So they did a bone marrow biopsy for this patient, and you can see this is particular, but the particles are empty, right? So why would have they done a bone marrow biopsy or bicytopenia to exclude what? This is power four. Anyone? Sorry, what is the age of the patient, please? The patient's age is 80 years old, and the patient had persistent anemia and thrombocytopenia. So the hematology department decided to do a bone marrow biopsy for this patient, and you are seeing the aspirate at power four at the moment. Hypercellular. Yes, okay. I will move to power 10 now. I see many megakaryocytes there. Yes, there are megakaryocytes. What is there anything you would like to comment about these megakaryocytes? These are all lobulated. So what do you think is the reason of why cytopenia in this patient depending upon this aspirate? This is one of the easiest aspirate to diagnose in the F exam in general. What do you think can be the cause of bicytopenia in an 80-year-old lady? Myelodysplasia. Okay. The answer is in this picture. If you know what are the features of that disease. This is megakaryocyte. So what are the features of megakaryocytes in MDS? They are unilocular. They have only one lobe here. This is the characteristic for myelodysplastic syndrome with 5q. You will confirm that on cytogenetics. That is obvious. But if you see aspirate or clot that has unilobulated or hypolobulated megakaryocytes, the patient has cytopenia, persistent cytopenias, then this is likely MDS with 5q. Let me focus another one. Will I convert to AML? Sorry. Will I convert into AML in future? Any MDS can convert to AML. H. Um, because this MDS, MDS in the patient can be therapy-related, radiation-related, or this one particularly we are discussing related to 5q mutation. Five Q mutation usually has lower chances to convert to AML. We haven't seen up till now with a patient having quite few MDS and later on they convert to AML. We haven't seen any yet in practice. And second feature of um, megakaryocytes in MDS is that they are small size. So small size, unilobulated, megakaryocytes in aspirate and clot is a feature of MDS. Then, small size megakaryocytes is also a feature of chronic myeloid leukemia as well, but they are not unilobulated. Unilobulation is a feature of myelodysplastic syndrome. So there are two conditions which has small megakaryocytes. One is CML, another is MDS. And MDS is the one which has unilobulated megakaryocytes or hypolobulated megakaryocytes. Hopefully, you will not forget that.
Okay, so this is a 40-year-old patient who presented to the medical Aztec because of constitutional symptoms, weight loss, um, lumps in the neck, and he has low white cell count and platelet count on the, uh, full blood count. The blood film was non-conclusive. No lymph node can be biopsied in him unfortunately. Because of cytopenias, the team decided to do a bone marrow biopsy for this patient, and you can see the refine in front of you. This is power four. So this patient has likely lymphoma because LDH is very high. He has constitutional symptoms. So I will go through this refine. Can you see any features in this refine that can help you in diagnosis? Any clinical hematologist who have seen the refine? So, um, this red is a normal bone marrow stuff. The problem is in the bluish area. The bluish part represents you infiltration of the bone. We but the position of this infiltrate is characteristic that helps you in diagnosis. Anyone who knows what can be the diagnosis here? There's a lot of silence today. I don't know why. From a BMS perspective, we don't usually look at the TR find. Yeah, that's why I asked from the clinical hematologist directly. What do they think? Bone marrow can be seen easily from the four power four. So this patient has a periticular infiltration. The bluish part, the periticular infiltration of lymphoid cells. And pariticular infiltration of lymphoid cells is a feature of follicular lymphoma. And this is one of the easiest Trine to diagnose in the exam. There are features of diseases that you should cram for the exam purpose. Other vacations normal in the in the trines. Yes. This patient has a bit more evacuation. He is a 30-year-old patient. If I said 30-year-old patient, his bone marrow should be 70% U, 70% cellularity should be there. But he has a little bit more of Vu. Cellularity is slightly decreased, but generally okay. Okay. You can see this infiltrate here. It's a periticular. The center of the Trine is all red. They'd be quite interesting for BMS to have a look at these. Be quite interesting for the BMS to have a look. Um, consult just tend to keep these to themselves, you know, but I'd like to see more myself. Um, sorry, there was a disruption of my connection. Can you please repeat? Yeah, the BMS is we like say, we don't usually look at these, but I'd like to be involved more. I'd like to see bone marrows more. But the problem is that it's very difficult to bring out the refine. As for it, we are BMS. They make a slide for us, but it's very difficult to bring out from this slide. It is given to me by my friend. Yeah, histology is given straight to consultants. We don't see these in histology. This is another small. Yeah. So this is another small infiltrate which is just next to the bone. And pariticular infiltration of the of the lymphoid cells is a feature of follicular lymphoma. If there is pariticular fibrosis, it is a feature of systemic monocytosis. The myofibrosis bone marrow is very typical. You will see all fibrotic bands in them. The DLBCL, you will see large lymphoid cells because it is a diffused lymphoma, a large lymphoid cell population in the bone marrow. Similarly, in ALL Trine as well, especially Bine, it's full of umats. We had seen previously an aplastic cell lymphoma, Trine which contain horseshoe shape cells, the specific cells for anaplastic cell lymphoma. We had seen previously Wens to Trine which shows nodular infiltration of lymphoid cells. So there are certain features of diseases in the Trine which if you remember, you will pick it up in the exam easily.
So that was it for today. Is there any question you want to ask? There was a lot of, I don't know why, maybe I started early. This interests you know, when you do this exam, are you actually sitting by a microscope or you just shown photographs? Unfortunately, you have to have your microscope in front of you. This is a three-day exam. So the first day is morphology. You will have a microscope in front of you. So there's usually quite a few slides to look at. Then yes, you have 10 slides for short cases, and then you have three sets of slides for long cases. Okay, okay. Right. So this was our 15th session, and if I have slides, I will show it for the next one as well. See you later. Have a good day. Okay, thanks so much. Cheers. Take care. Thank you. Thank you.