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 here today. So this is a, uh, 46-year-old male admitted to ICU with biliary sepsis. The WBC count is 44 and the plt count is 600, and hemoglobin is, uh, 99. This is power 10. Deficient, 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 crystals 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 expect fibrinogen to be like four or five because it is an inflammatory response, um, 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 DI. He is, um, 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 diic 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 DI. Maybe early in sepis, the thrombocytosis, but of the DI, 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 bacterials. 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 is to one fragment is there. Just no. So you will report the blood f for the exam purpose that, uh, this this Blood Fame contain leucocytosis and thrombocytosis. There are multiple shites in the blood. No blast. Multiple, uh, toxic granulation in the nutrifil. Multiple toxic granulated nutrifil and, uh, 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, the people in the exam make a mistake. They see that the, uh, W cell count is, uh, 50 plus. This must be a CML and they make up things. So high workel 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 phone 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 lift 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 metam miloy. This one is a miloy. This big one is, uh, prosite. 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, uh, 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 moid 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, liid reaction and the, uh, CML. Why are there more Bas of LC than CML? The 922 translocation and mutation result in formation of all myoid peak, including basophil, euil as well. H, this the only explanation. So how will you report this Blood f? Um, can we see aaside just to compare with the the size of, uh, RBC lymy? It would be very difficult because the film is full of my PE. Uh, maybe this one is lymy, but this one is nrbc. This one looks like a and it, uh, size is all same as the NVC as the red cell and the size of the nucleus is same as the red cell. This is normal setting. Yes. So nortic normal chromic anemia. Always comment on the, uh, abnormality first. Okay. We'll say Le neutrophilia or leyos with the bands, metam myoides, myoides. I think the blast should be, uh, noted as well. Yes. The blood contain liosis. There are multiple neutri, band form, metam myoides, myoid, proside, blast form, multiple nrbc along with basophils and EOP. Creed count is slightly increased. Red cells are normal. The blood fin picture is consistent with, uh, most varable diagnosis of chronic myo leukemia, or you can say it is most likely a bio proliferative neoplasm, probably cing my 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 food 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 Stog gentics 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 poemia? What are the features that made you think about this is Poli? Well, the actual red looks really high. M is probably high too, the looks of it. Hocr above 49 and feale and 52 in May. The one clue is that that they will give you, uh, f BC which will show either high hemoglobin or High hemat. 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, uh, 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 FS, 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, 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 M PL? So whenever the counts are high, uh, do not jump to, uh, 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, uh, solid organ cancer secreting a lot of arthropo. Maybe maybe he has this diagnosis since birth, congenital poly. Always exclude the secondary does of Roc cytosis. 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 C program. If it, 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 EPA, very or any pathological cancer, his count will be high. The main important thing here is to check EO level of this patient. If the EO level is low and cell count is high, it means there is some malignant element is involved. If the EO level is high and this is the blood picture, then I would think this is secondary poemia because that cause leads to elevation of erotin. And now, as a response, the, uh, red cell count is high. Similarly, in thosis, you exclude first the secondary cause. The common cause of chomos cytosis in UK is already deficiency anemia or infection. And rule out the other causes. If no secondary cause found, then you contact the hmds for MPN panel or J 2. So if you jump directly to, uh, MPN panel or J 2 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 Boo 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 inop. Sorry for interruption. So B AB B KU B 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, PL is a bit low. So, so what comes to your mind when you have a 24 year old patient with cervical lymphadenopathy? What are your defion? Infectuous. Infectuous mononucleosis. Other viral infections, uh, lympho proliferative disease like lymphoma. And, um, yeah, this is what came in my mind. Which comes to your mind? Hkin. Yes. Hkin is common in y. All your H patients will be less than 30. Yes. And they have either copy or Medias. So this is a quite large lymphy, but it has a bopic cytoplasm and it is coping this RBT. And this is a mature one. And there is no blast in it. What is the lymph count? Lite count is the white cell count is 13. The lym side 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 nucle. No nucleoli in this cell. And these are the features of Rea. So what test you will do to confirm your diagnosis? Bletry. Why to exclude what? What probably? Sorry, exclude what? Usually we use the flo. 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, uh, patient. This is reactive lymphocytosis. I was think about ABV infection. Yeah. Monos sport test. Monos sport 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 a case of, 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 depend on the virus as well. If you have seen the blood film of a whooping cough, baby, it has a smaller cells with, uh, 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. Coping here. This one and that one. And the history matches, uh, infectious mosis as for. Yeah. So this is a 70 year old patient with progressive fatigue and paraprotein was 66. We thought that this may be Myoma. We did a biopsy for her and this is the aspirate which is particulate. You can see the particle here. This is power four. Aspirates 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 them, you will see the warm on power four first. Andine 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 esperate. Any comment on this ES? There is neutr. There is myoid 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 cell in the bone marrow. And the craft feature was was positive. CB me, um, calcium was high, uh, renal functions were abnormal, anemia was there. And there were five, uh, letic region on the, uh, low do, uh, full body CP SC. And the parins were IG as well. It fits the criteria of Myoma. And she had 14 16 translation, 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 ther 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 Wen room, but the book have mention flame shaped cells in IG. But I, yeah, but I have seen most of them in the Wen room, bone marrow, not in any other. Like these are plasma cells, but this is not flame shap. Only these few projections here, but I will not call it them as a flame shap. Typical flame shap. I think like with the spindle projections. Yeah, yeah. But most of them are without any project. 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, uh, patient because bringing out refine is a bit difficult because of legal purposes. As far as we can stain aspirate self in the laboratory. We bring out as this is join plasma cells with, uh, Ecentric nucleus with, uh, hello 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 intop plasmic. Many of them. But the those are the features of Wen stor, uh, not commonly seen in multiple Myoma 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 session for the part two people. How to prepare part two. After that, we will resume our. Okay. Thank you. Okay. Thank M appr. Thank you. Appreciate. Bye. Thank you. Thank you.