Transcription
I would like to welcome you today for another day of a series of orbitals, which are organized by the Solid Society for Blood Disorder. Today is the second day of the preferable morphology course crash course. And today's talk, uh, will try to cover WBC morphology and hematological emergencies. So it will be over one and a half hour. And please, please type your questions, comments on the Q and A section. Please be reminded that the webinar is recorded and will be available through SSPD social media, social media accounts. Without any further, uh, dudes, my great pleasure to introduce Dr. Haytham. Uh, Dr. Haytham is a hematopathologist at King Faisal. He was trained in MD Anderson, and we are looking forward to his talk. Please be reminded that this series of webinars are sponsored by other secretaries from Abut. Without any further due, right, Mike is yours. Can you see my slide? Not yet. If you can share the screen. Let me share the screen now. It's clear now, but if you can put it in the presentation mode. Okay. Good evening, everyone. In this presentation, I will talk about the different non-malignant leukocytes disorders, in other words, benign white blood cell disorders. So I'll try my best to summarize and make it, make it simple for you. So let us start with case number one. This is a peripheral smear from a 30-year-old female who came for a general checkup. As you can see here, here laboratory data shows normal CBC. But let's identify the cells that are shown on this image. So these cells are neutrophil, and this is eosinophil. This one, basophil, and this one, monocyte, and this one, lymphocyte. So segmented neutrophil is the mature cells of the myeloid series that constitute 40% to 70% of the white blood cells, of course, in the peripheral blood. This is band cells. So band neutrophil is the immediate precursor of the segmented neutrophils and it constitutes around 5% to 10% of the white blood cells in the peripheral blood during normal conditions. This is monocytes, which looks larger than neutrophils and shows abundant gray or gray-blue cytoplasm that may contain vacuoles, as you can appreciate here. The chromatin is condensed, but is usually denser than that what you can see it in the neutrophils or lymphocytes. Eosinophil is characterized by coarse orange granules of uniform size and is similar to a neutrophil in diameter. And normally, the nucleus demonstrates condensed chromatin and nuclear segmentation with two and sometimes three nuclear loops. This is basophil, which is the least common circulating granulocyte. And this is unlike neutrophil, which shows three to five nuclear lobes. It typically has only two prominent nuclear lobes and cytoplasmic with numerous dense purple basophilic granules, often obscuring the nuclear details. This is typical lymphocyte, which is slightly larger than normal RBCs with scant to moderate pale blue cytoplasm, round nuclear contour, mature chromatin, and inconspicuous nuclei. This is large granular lymphocyte, which is medium to large cells with round nuclear or nucleus, dense chromatin, and no visible nuclei. The cytoplasm is moderate to abundant, clear, and lightly basophilic compared to the, the previous previous typical lymphocyte and contain several coarse, uh, uneven, uh, distributed small, uh, eosinophilic granules. So this diagram shows how these, sorry, cells maturation sequence. So we have common myeloid progenitor cells and common lymphoid progenitor cells. So common myeloid progenitor cells create three types of progenitors: granulocyte-monocyte progenitors, which give rise to neutrophils and monocyte and macrophage. The second one is eosinophil-basophil progenitor, which give rise to eosinophils and basophils. And megakaryocyte-erythrocyte progenitors, it give rise to platelets and erythrocytes. In the other hand, there is common lymphoid progenitor, which would give rise to the lymphocytes, either B and T. So each of these divided and matures into cells known as blast, one for each cell line, from where they divided and differentiated to different subtypes. This figure demonstrates the normal maturation sequence of neutrophils, starting from myeloblast, which is the early stage of neutrophils, then it matures or differentiates into promyelocyte, then myelocyte, after that metamyelocyte and band neutrophils, and finally segmented mature neutrophils. So in the peripheral blood, usually you find segmented neutrophils and band neutrophils.
Case two. This peripheral blood smear is from a 50-year-old woman with septic shock. So her laboratory data shows white blood cells 15.6 and low red. So she has, before going into detail, I just want you to recognize the abnormal finding just by looking up to the CBC and peripheral blood morphology. So based on the peripheral, the smear on the CBC result and peripheral smear, the patient has abnormal count, as we said, high white blood cell count and low hemoglobin and platelet, along with some morphological changes in the neutrophil.
Case three. This peripheral blood smear is from a 30-year-old male presenting with systemic sclerosis. Again, before going into the details, based on the CBC and peripheral blood morphology, this patient has abnormal count, low white blood cells, along with abnormal neutrophils. So now let's first have an overview of the different white blood cell disorder classification. So we categorize these disorders into quantitative, where there is an alteration in the number, or qualitative, where there is morphological or functional alteration. Quantitative can be subdivided into two again, which are acquired, including reactive process or inherited, and malignant or clonal, which will be covered tomorrow. The acquired alteration usually described by an increase or decrease in the white blood cells. For qualitative alteration, it can be categorized into three conditions: morphologic abnormalities, or with normal morphology, and those with morphological changes. So each white blood cell, we have the neutrophil, eosinophils, basophils, monocyte, lymphocytes, may either have a qualitative or quantitative abnormalities. Many times, almost all cases show quantitative and qualitative abnormalities parallel together. To discuss the quantitative abnormalities, it is necessary to define the different reference ranges for the white blood cells count and for its subtypes. It is also to remember that these reference ranges may vary between laboratories because of different cell counting procedures, instrumentation used in the laboratories, methods that used in the validation to establish these values. Also, different reference values may be given to different patient populations. So this is the reference value that we followed in the King Faisal Specialist Hospital, and these are some related important terminology that we use it when we are dealing with quantitative white blood disorders. Leukocytosis, simply defined as leukocyte count above a normal range. Leukopenia, again, which is defined as having white blood cell count of less than a normal reference range. And pancytopenia, uh, this term is given when there is a decrease in all other different, all other different cell types also.
So, going back to the previous case to discuss it in detail. So this is a peripheral smear again from a 50-year-old woman with septic shock. Her laboratory, as we said, it shows leukocytosis, and the differential shows mainly neutrophils that represent around 85%. So the leukocytosis is characterized by increased neutrophils, which we call it neutrophilia, which is an increase in the neutrophil count above the reference range. And the three main causes of neutrophilia are infection, inflammation, and malignancy. Also, it either be pathologic or non-pathologic. In other hand, it can be a result of primary causes like MPN or secondary causes like infection and others. Leukocytosis, as we said, is characterized by increased neutrophils, of which many show toxic changes. So the toxic changes include toxic granulation, which means granulation is more prominent than what it is typically observed or seen in the normal neutrophil. So this is a normal neutrophil, and these two neutrophils showing increased granulation or toxic granulation. The second change is toxic vacuolation. Again, compare it with the normal. There are no vacuoles in the normal neutrophils. However, this cell or this neutrophil shows prominent vacuoles. The third change is Dohle bodies. So basically, these are blue or gray-blue round, elongated shape inclusions found at the periphery of the cytoplasm near the cell membrane. So either toxic granulation or Dohle body, if present in an individual neutrophil in isolation, it will be sufficient to designate a neutrophil as toxic. On the other hand, vacuolation can be due to either toxic changes or degeneration process. Therefore, the process of neutrophil with vacuolation as a sole finding should not be labeled as toxic vacuoles unless combined by toxic granules and or Dohle bodies. Leukocytosis in septic shock and other reactive conditions may be so high as to mimic leukemia. Then it is referred to as a leukemoid reaction, where there is an increase in the neutrophils in addition to some left shift. Infection, trauma like burns, underlying cancer, especially when they show paraneoplastic reaction, and drugs like G-CSF may cause leukemoid reaction. The leukemoid reaction may be confused with MPN, including CML, atypical CML, or even CNL, chronic neutrophilic leukemia. So how can we differentiate these? So in leukemoid reaction, neutrophils are dominant and usually show toxic changes, toxic granulation, and Dohle bodies. While seen in the CML, it shows some left shift with the expansion of intermediate stage myelocytes and metamyelocytes, as we can see here, left shift, some immature myeloid precursors, in addition with basophilia and eosinophilia. Therefore, careful attention to cytological characteristics of the neutrophils, for example, toxic features, and presence of an accompanying left shift, as well as clinical and laboratory features, for example, history of infection, trauma, drugs, is required to arrive at the correct interpretation of the peripheral blood smear.
Case three. This peripheral blood smear is from an 11-year-old girl presenting to the emergency room with wheezing, and she is diagnosed with asthma. So her CBC showed a high white blood cell count, and as you can appreciate here, his eosinophils. So her peripheral blood shows a lot of eosinophils because her differential, or the leukocytosis, is characterized by increased eosinophils. So this patient has eosinophilia, and the eosinophilia can be primary or secondary. Primary, that means eosinophils are neoplastic, such as that observed with MPN, or secondary, like that involved with reactive processes like infection, mainly with parasites, or allergic reactions like asthma or atopic dermatitis. Eosinophilia also can be short-lived or prolonged. In most cases, short-lived eosinophilia is mainly due to many potential secondary causes. In cases of prolonged eosinophilia, especially at high levels, it is usually associated with potentially primary eosinophilic disorder. A detailed clinical history and laboratory investigation is critical for appropriate management of patients with eosinophilia. A patient history and physical examination are important to determine the presence of any risk factors or signs to guide subsequent laboratory testing.
Peripheral blood smear has limited utility to distinguish between reactive and neoplastic causes of eosinophilia. However, some mild dysplastic features, including hypogranularity or hypersegmentation, more than three lobes, and vacuolated cytoplasm, can also be seen in the reactive conditions. However, frequent or marked dysplasia, especially when you have eosinophils with abnormal coarse granules like this one, coupled with the dysplasia in the other cell lines or coupled with blasts, this finding further suggests a neoplastic process. Again, examination of the peripheral blood carefully, especially the tail of the smear and the edges of the smear, is very important to reveal. It may show some parasites if a clear reactive cause is not identified. Further investigation, including a bone marrow biopsy, cytogenetics, and other molecular testing, should be performed. Overall, eosinophilia is an effect of a variety of processes and requires a thorough investigation and clinical correlation.
Case four. So this peripheral blood, the peripheral blood is from a 19-year-old male who complained of fatigue and fever. So his white blood cells is high with normal RBCs and hemoglobin and platelet count. Again, the leukocytosis is characterized by increased lymphocytes, and these lymphocytes look a little bit atypical if we compare it and different if we compare it with the normal one. So lymphocytosis in general can be divided into those with reactive morphology and those without reactive alteration. Causes of the reactive morphology are usually viral infections like CMV, HIV, and herpes. Although other bacterial infections also may cause an increased lymphocyte, like syphilis. And an example for an unreactive morphology would be whooping cough that caused by Bordetella pertussis. And if you want to differentiate between the reactive lymphocyte from the other variant, the key distinguishing feature for the reactive lymphocyte is their wide range of cellular size and shape, as you can appreciate in this picture, as well as nuclear size, shape, and chromatin pattern. This is another picture for the reactive lymphocyte. So reactive lymphocytes usually have abundant cytoplasm, which is intensely basophilic, and sometimes shows cytoplasmic bleb formation, and this feature, usually it reflects the immune process or immune stimulus that initiated by a viral infection. In contrast, while lymphoma conditions exhibit a more monotonous population of abnormal lymphocytes. So for this case, further testing demonstrated a positive monospot test, confirming infectious mononucleosis.
Case five. This peripheral blood smear is from a 35-year-old man with no significant past medical history, presenting with headache and easy bruising. Laboratory data includes white blood cells showing a low count around two, RBC and hemoglobin also reduced, and platelet count shows thrombocytopenia, severe thrombocytopenia. So generally, the patient is having has pancytopenia. So the leukopenia here is characterized by the presence of these abnormal cells. So these cells, again, this is another picture for these abnormal cells. So basically, these are abnormal promyelocytes, which are considered as blast equivalents in the background of leukemia. And we want to compare these cells with the normal promyelocytes. So promyelocytes are round to oval cells that are generally slightly larger than the myeloblast, but the abnormal promyelocyte differs from the normal promyelocyte in several aspects. The abnormal promyelocyte nucleus is usually folded or bilobed, like here. This is another picture of bilobed cells, often with overlapping nuclear lobes, and the distinct Golgi zone is typically absent in these abnormal promyelocytes. So this is a normal promyelocyte showing Golgi zone. The pre-nuclear halo, which is disappeared or absent in the abnormal or leukemic promyelocyte. Cytoplasmic granules, while abundant in the classic hypersegmented form of APL, may differ in appearance and often being coarser and darker than those seen in the normal promyelocyte, and slightly yes, and unusually obscure the nuclear details. The abnormal promyelocyte frequently contains numerous overlapping Auer rods and Döhle bodies. That showing multiple Auer rods can be called cells in the macrogranular variant of APL. Very few granules may be visible, like this case or this picture, and those granules present may be very fine. So this patient has APL, and patients with APL typically present with bicytopenia and variable degree of anemia and thrombocytopenia. However, some cases can present with leukocytosis, especially in the microgranular variant or microgranular APL. It can be subdivided into two morphological features: hypergranular, which is typical, and hypogranular and microgranular variant. I will variant APL. The neoplastic cells in the hypergranular typically contain numerous dense, dark purple granules and often obscuring the nucleus, and also it shows frequent Auer rods, occasionally forming bundles, typically present and called cells. And this is common. In contrast, the hypogranular or microgranular variant, as the name implies, it displays sparse to inconspicuous granules. APL is considered as one of the most emergency cases in the serious cases in the hematology service that need quick action because of the high rate of death, mainly due to coagulopathy. So once you have a case, you suspect this is APL, just inform the clinician to give him time to start the treatment as soon as possible. In addition to the CBC with differential and review of the peripheral blood smear, all patients with a presumptive APL diagnosis must undergo an urgent laboratory evaluation. And these evaluation or these investigations include a coagulation panel or coagulation screen to evaluate the presence of DIC, flow cytometry and immunophenotyping, cytogenetics, and molecular analysis to confirm the diagnosis and to confirm the presence of underlying PML-RARα translocation. Be careful in cases with markedly decreased white blood cell count. The abnormal promyelocytes are usually sparse in the peripheral blood. Therefore, a careful morphological evaluation of the peripheral blood smear with identification of abnormal cells is crucial. So this is why usually when you have a smear from a markedly decreased white blood cell count, you have to go and find these cells in the thick area and also in the tail.
So this chart would summarize all the possible quantitative disorders, starting with leukocytosis, which is divided into neutrophilia, eosinophilia, basophilia, monocytosis, and lymphocytosis. And this chart again shows the quantitative disorder, which is mainly in the leukopenias, so neutropenia, eosinopenia, basopenia, and monocytopenia, and lymphopenia. So in the next slides, we will discuss some qualitative white blood cells with abnormal morphology. But before that, for the quantitative abnormality with normal morphology but with functional defect, the best answer, the best example to be mentioned is chronic granulomatous disease, which is caused by a mutation in the NADPH oxidase gene, which leads to failure of neutrophil respiratory burst following phagocytosis.
Next, case number six. So this peripheral blood smear is from a 30-year-old male presenting with systemic sclerosis. So his laboratory data shows mild leukopenia, almost normal red blood cells, hemoglobin, and platelet. So any guess the abnormal cells, what is the abnormal cells? And I guess in the Q and A, let's have some interaction. Yes, so these neutrophils show Pelger-Huët nucleus. So if we compare this nucleus with the normal, as we said, the segmented neutrophils show segmented and more than two nuclear lobes, but these cells show only two lobes. So neutrophils with two round nuclear lobes connected by a distinct thin filament are designated as neutrophils with Pelger-Huët nucleus or nuclei, or as Pelger-Huët cells. So Pelger-Huët cells, Dr. Carr, Pelger, a Dutch hematologist, was the first one who described this morphological feature in 1928. And the nuclear chromatin in the Pelger-Huët cells is generally denser than in the normal cells, as we can appreciate here. So it's denser, and this feature helps to differentiate the Pelger-Huët cells from the normal neutrophils and their precursors, which have more open or lightly staining chromatin. So neutrophils with identical nuclear features can be seen in Pelger-Huët anomaly, which is an autosomal dominant inherited disorder, which was described by pediatrician G.J. Huët in 1932, and occasionally observed in association with other clinical conditions, including MDS, infection, and drugs. Also, where the proportion of affected cells in these situations is variable, but typically only a small subset are affected, which is a clue, since individuals with true Pelger-Huët anomaly usually demonstrate this abnormality in the majority of the neutrophils. When these cells are seen outside of the context of the congenital abnormality, they are usually referred to as neutrophils with dysplastic nucleus or pseudo-Pelger-Huët cells.
Case seven. So this peripheral blood smear is from a two-year-old boy who presented with delayed speech and skeletal deformities. His CBC shows normal white blood cell count. The patient is anemic and has mild thrombocytopenia. So any guess what these cells? No, any other guess? Yes, so these are abnormal large coarse inclusions or granules that, yes, these neutrophils showing large coarse inclusions that refer sometimes as Reilly bodies. That's true, in the cytoplasm of the neutrophils. So if we compare it with the normal neutrophils, and this is neutrophils showing toxic changes, so it's coarser and darker. So these are Reilly bodies, which correlate or can be seen in the Alder-Reilly anomalies. So Alder-Reilly anomaly was first described by Alder in 1939 and by Reilly in 1941. Accordingly, it is known as Alder-Reilly anomaly. It is again an autosomal recessive inherited disorder characterized by the presence of large eosinophilic and basophilic granules in the cells of the myeloid and lymphocytic series. It can be associated with mucopolysaccharidosis, which is a group of metabolic disorders that caused by the absence or malfunctioning of lysosomal enzymes that needed to break down molecules called glycosaminoglycans. However, these cells should not be confused with the toxic granulation in the neutrophils, which are characteristically present in the background of, as we said before, in the background of sepsis and can be seen in the background of infection or myeloid growth factor therapy.
So this peripheral blood smear is from a two-year-old girl who presented with fever, diarrhea, fatigue, and abdominal distension for the last 10 days. Skin examination was remarkable with patchy hypopigmentation around the face, trunk, back, abdomen, hands, and feet, along with hypopigmented silver-gray hair. Her CBC shows leukopenia, anemia, and thrombocytopenia. So it's pancytopenia. And in this figure, the neutrophils reveal abnormal giant lysosomal granules, as you can appreciate here, which also can be seen in the granulocyte precursors, also in the lymphocytes and monocytes. So if we compare these cells with the normal neutrophils, so easily you can appreciate the difference between this abnormal finding with the normal neutrophils. So any guess what is this cell? True. So this is, this is another example of the abnormal inclusions that can be observed in the lymphocytes. As you, yes, most of the people mentioned, yes. So this is Chédiak-Higashi syndrome. Chédiak-Higashi syndrome is a rare autosomal recessive condition that was initially described by Beguez-Cesar in 1943 and Chédiak in 1952 and Higashi in 1954. This rare autosomal recessive disorder arises from a mutation of a lysosomal trafficking regulator protein, which is also called CHS1, Chediak-Higashi syndrome 1 gene, which leads to a decrease in phagocytosis. Chediak-Higashi is characterized clinically by partial oculocutaneous albinism, which is reduced pigment in the skin and eyes due to defect in the melanin granules, and also characterized by recurrent pyogenic bacterial infections due to abnormalities in the granulocytes. Also, bleeding, neurological abnormality or neurological deficit are also common. So this disease, Chediak-Higashi, can be categorized into classic and atypical or mild forms. Individuals with atypical forms may have fewer or less severe infections and milder symptoms. Children with the classic form of the disease are at risk for developing the accelerated phase. The accelerated phase usually occurs in up to 80% of patients and can occur at any age, and the accelerated phase is caused by an excess production of lymphocytes by the immune system. And patients can develop symptoms such as fever, swelling of lymph nodes, or enlargement of the liver and spleen, also anemia, pancytopenia in general. And this is a serious condition and needs to be treated right away. Griscelli syndrome, also known as Chediak-Higashi-like syndrome, is a rare inherited disorder that is characterized by partial albinism and abnormalities of platelets and white blood cells. The symptoms of Griscelli syndrome and Chediak-Higashi are almost similar, but on laboratory analysis, the white blood cells do not have the giant granules like those seen in the Chediak-Higashi syndrome. Therefore, the diagnosis is made differentially based on these white blood cell granules.
Okay, case ten. So there is no case scenario. So what you can, any suggestion with this abnormal neutrophil? Called May-Hegglin. Another suggestion is. So this neutrophil shows Dohle-like inclusion bodies along with large like inclusion bodies along with large or giant platelets. That's true. This is again, if we compare it with the normal neutrophils, as you can see, there are no any inclusions similar to this one. So this is May-Hegglin. And normally, so May-Hegglin anomaly will have Dohle-like inclusion bodies in the neutrophils, also in these eosinophils or basophils, as well as monocytes. Thrombocytopenia and giant platelets also can be seen concurrently. The disorder was first described by Richard May, a German physician, in 1909, and was subsequently described by Robert Hegglin, a Swiss physician, in 1945. Uh, the May-Hegglin anomaly is inherited in an autosomal dominant fashion, owing to a mutation in myosin heavy chain 9. A May-Hegglin inclusion is due to aggregates of non-muscle myosin heavy chain 2A.
Case eleven. This is a 50-year-old woman who presented with two months of fever, chills, diarrhea, dry cough, and progressive dyspnea on exertion. Her CBC shows pancytopenia. And this is the peripheral blood. Any suggestion what you can see in this peripheral blood? Leishmania? No. Any other suggestion? Blue crystals? Okay. Malaria? No. Okay. So this figure is showing leukocytes with or phagocytosing yeast forms. So this yeast form is Histoplasma capsulatum. So usually Histoplasma, it will be engulfed by neutrophils or monocytes or histiocytes. It's not like Leishmania, which is more often extracellular, not like Histoplasma. Histoplasma is more often intracellular. So this infection is reported to be present in 5% to 20%, I guess, of its patients, and in 95% of the cases, it is manifested in its disseminated form. Serum antibody and or antigen research can make the diagnosis, but the demonstration of the agent by culture or histopathological examination remains the gold standard method. So remember, Histoplasma usually intracellular inclusions, and this is a fungal infection. But this is a picture. Any guess? No. So this is abnormal invasion, and it's distributed also extracellular, in addition to intracellular. So this is Leishmania inside and outside of the macrophage, characterized by kinetoplast and characteristic double dot appearance. So Leishmania is usually distributed intracellular and extracellular of the cells.
Other findings that you can see it in the, in the white blood cells. So any guess what are these findings? Yes, this is, this is peripheral blood film from SLE patient. True. Yes, this is LE cells. That's correct. So this is engulfed material, usually coated by antibodies, as LE bodies, and then ingested by a viable neutrophil, and as you can see here, the nucleus of the neutrophil is pushed to the periphery. So an LE cell is an in vitro phenomenon, rarely found in vivo. Anticoagulant blood is agitated inside the tube by an unknown mechanism, so that nuclei are released from the disrupted leukocytes, and another neutrophil will ingest this body, which is called an LE body. Again, this LE cell is characteristic of SLE.
This smear, and I guess what are these cells? What are these cells? Yes, this case is from CLL, but what I mean, these cells, what do you call them? Döhle bodies? No, the smudge cells. Yes, I'm receiving some here. True. So these are smudge cells. This is a high power of these smudge cells. So also known as basket cells, and these cells are ruptured white blood cells, leaving their nuclei to be free. And they can be pathologic and non-pathologic. A non-pathologic cause may occur during the smearing process. So smudge cells are produced if there is heavy pressure on the spreading slide, and a pathologic cause of smudge cells may be due to leukemia. And in the lab, an albumin preparation can be used when many basket cells are present for cellular preservation in order to identify these cells.
Okay, what are these cells? It's simple, and I guess hypersegmented neutrophil. Yes. So this is hypersegmented nucleus. Remember, the normal neutrophils have an average of three lobes and always, always fewer than five lobes. Hypersegmentation or hypersegmented neutrophils are usually seen in megaloblastic anemia, and it is considered sometimes as a dysplastic feature if it's combined with other dysplastic morphological findings. I think this is my last slide. Thank you for your attendance. So now I can open the window for any questions. So there is one question: How can we differentiate between LE cells and hemophagocytic cells? Usually, hemophagocytic cells, you can see the monocytes or the histiocytes engulfing the other viable cells like neutrophils or RBCs or nucleated red blood cells and the platelets. And hemophagocytosis is mainly observed in the bone marrow more than in the peripheral blood. But in the LE cells, it's large red inclusions, and it's only one inclusion, and it's inside the neutrophil, pushing the lobes of the neutrophil to the periphery. So it's easy to be differentiated. That's true. This is another question: Can smudge cells occur due to the wrong way of making the blood smear? Yes, it can be. Because old time, when we prepare the smear, we prepare manually, but right now, we reduce this artifact by using the machine. But true, if we want to prepare and we apply more pressure, we can produce more smudge cells. Yes. What are the dysplastic changes in the white blood cells? There are a lot of dysplastic changes, and I will leave this question to my colleague, Dr. Rana, tomorrow, because I believe she will discuss some cases for MDS. So now, I discussed only the benign white blood cell disorders, and I believe I'm sure Dr. Rana will go through these features in detail. The next question. Yeah, can you show more slides regarding Leishmania? The important thing regarding Leishmania, it is extra and intracellular inclusions. And it's smaller than the other inclusions when we compare it, for example, the histoplasma. Histoplasma is large, round, dark inclusions. This is why it's called capsulatum. So it's easily can be differentiated from the small inclusions that are distributed extra and intracellular. And this is what we call it kinetoplast, and usually it's characterized by double dot appearance, not like the histo, Histoplasma.
What other question? Um, this is a good example. What is the source of Auer rods and from where it is coming? So Auer rods are the abnormal collection of the primary and secondary granules in the blast. So there is a lot of, when you have a leukemia process, so these cells behave abnormally and in crazy ways. So these are abnormal collections of the granules, mainly primary and secondary together. So this is how the Auer rods, its form. Smudge cells could be of any type of cells, mainly lymphocytes, but yes, it can be any type of cells. Sometimes you will find some ruptured neutrophils and eosinophils and basophils with the same process. Okay, next question. Can you please? Yes, I think Dr. Muhammad Muhammad, he went through this question yesterday. Can you please describe the difference between a thick and thin film for malaria? So usually, thick film is used to identify if there is malaria or not, and the thin film is usually used to identify the species. So this is the main issue. So first, you will go through a thick film just to identify if there is malaria, then after you, after the thick film, it's positive for malaria, then you will go to the thin film to identify what kind of species that you have it in the same film. Recording, I think from the SSPD website, can show Auer rods seen in mature cells? Yes, Auer rods. Be careful when you deal with APL, and the main treatment for APL is ATRA, which makes these neoplastic or abnormal promyelocytes to start differentiating. So some, if you don't give another chemo to kill these cells, of course, some of these cells, when they start differentiating, it can reach to a level or a stage of neutrophils, and still there are Auer rods. And in the follow-up bone marrow, please be careful when you examine the follow-up bone marrow or peripheral blood for the patient who diagnosed with APL. Do not just wait and examine or look for the promyelocytes. No, also examine the neutrophils very carefully because sometimes there will be abnormal neutrophils still keeping something of Auer rods. Okay, if we have Auer rods in the neutrophils, do we consider it as a part of dysplasia? And I will consider this as a part of residual disease, especially in the background. So the Auer rods, you will never see the Auer rods in any other context other than acute leukemia. However, some very, very rare findings show lymphocytes with Auer rod-like inclusions, but it does not relate to the leukemia process. Okay, how can we differentiate between monocyte and reactive lymphocyte? As I said earlier, monocytes are large, larger cells, and usually show vacuolation and blue-gray cytoplasm with indented nucleus. But the reactive lymphocyte, its size-wise, it's smaller than a monocyte, and the N:C ratio is high, showing scant little cytoplasm, dark blue with very condensed chromatin and inconspicuous nuclei. And if we compare it with the monocyte, the monocyte chromatin is more open. If we compare it with the lymphocyte, and also one of the key features that I tell my colleagues always, always look to the other cells to compare the normal cells with the one that you are examining. So if you have a typical lymphocyte, so you can compare it with the other normal lymphocytes in the same field or in the same peripheral blood smear. Okay, is there any? I think this is in the microscope out and depends on the good new machine that prepares slides and send it electronically to the clinician together. Yes, regarding this question, with this microscope out of depending, yes. So nowadays, there is an era of technology. There is something called digital pathology. So they can use artificial intelligence technology. So computers can recognize these cells by giving all the pictures and millions of pictures of the different variants and different shapes of the cells, and the computers start to recognize these cells and memorize these morphologies and start identifying the cells. So it's very advanced technology, and some centers in the US and Korea start using this artificial intelligence in the lab, and hopefully one day we can use it also in our laboratory. Okay, reactive lymphocytes, as I said, reactive lymphocytes mean lymphocytes showing or start showing some variation or alteration in the morphology that not similar to the normal one or the typical classical one, because the classical lymphocyte is small cells, double the size of the RBCs, condensed chromatin, high N:C ratio. But the reactive one starts showing some changes in the morphology by showing some abundant cytoplasm. The color of the cytoplasm starts become more darker compared to the normal, the classical one, but the morphology of the nucleus is still the same: condensed chromatin, inconspicuous nuclei, because whenever you find the chromatin is opened or fine with clear nuclei, so that means this is an immature form of the lymphocyte, can be prolymphocyte or can be blast. So this is how we can differentiate. And always, always, as I said, compare the cells that you are or the suspicious cells with the other cells in the same field or in the same slide, because lymphoma cells usually show monotonous informal morphology, however, reactive lymphocytes show variation of morphology. This is not a hundred percent generally in most of the cases. Okay, next question. Yeah, this is a good question. Why white blood cells qualitative and quantitative abnormalities in the COVID patients? So COVID patients usually presented with severe lymphopenia and severe, severe lymphopenia, and the morphology of the lymphocytes in the COVID patient is really, really atypical and shows very, very abnormal morphology, but not to the level of blasts. You cannot confuse yourself or become confused. This is blast? No, this is mature lymphocyte, but it's very abnormal, atypical due to the infection. But usually, COVID patients, they present with severe lymphopenia. So it's sometimes difficult to find a good number of lymphocytes to give a good morphological assessment. I am slide. Okay, some questions I couldn't understand what exactly you mean, but let me go through other questions. Between. So yes, what is the difference between reactive lymphocyte and atypical lymphocyte? So in the older days, the word reactive is similar to atypical, especially in the hematological field. But atypical, and in anatomical pathology, it's more likely to be abnormal or neoplastic. But in hematology, atypical, it's more likely to be reactive. This is why in the report, some people, some pathologists, they use reactive/atypical lymphocyte rather than using only atypical only, because it will make the clinician a little bit confused. So and I prefer if you want to use reactive alone, it's fine. If you want to use atypical, also just put reactive or atypical/reactive lymphocyte. But if you want to say this is an abnormal lymphocyte, you can say atypical or abnormal atypical lymphocyte. Okay, in case of plaque derivation, it shows what we are as a clinician in hematology and oncology want the slide in the system, same as radiology picture. Um, and I think this is something like again under the digital pathology and artificial intelligence. So hopefully in the future, we can reach this point to upload all the morphology in the system. How common to see lymphoplasmacytoid cells in COVID patients? Not sometimes, yes, because lymphoplasmacytoid cells, it's a kind of morphological alteration in the lymphocyte that correlates with the infection, especially in viral infections. So again, COVID patients usually present with lymphopenia, so it's hard to find a good number of lymphocytes to go through them and to examine their morphology thoroughly. Yes, is there any case slide for infectious mononucleosis? The case that I saw it in my presentation, it's from a patient who has infectious mononucleosis. Okay, next question. What is the significance of finding toxic granulation in a normal, not septic individual? Usually, the toxic granulation, it's mainly correlates with the infection and inflammatory process, and the degree of the increased granulation and how much it's dense and darker, it also correlates with how the patient can correlate with the viral load or the bacterial load in the body. So in a normal person, it's obviously you should not see neutrophils with toxic granulation. But sometimes this may, in the staining process, may make these neutrophils to show their granules more darker, and it can be a false finding, it's not a true finding. But in general, toxic granulation, you only see it in the reactive process, as I said, infection, inflammatory process, drugs, secondary to paraneoplastic condition in some cancers. Okay, Dr. Faisal, Anna, I will, and I will really, I will meet with the head of the section and with the head to let them know about your idea to send all these pictures through the system. Don't worry. Yes, what is the best area of the smear to detect the cell inclusions? Again, the best area for the peripheral blood examination is the body of the slide. So but of course, if you find your answer and your evaluation is sufficient by reviewing the body of the slide, so no need to go to the tail or to the head of the slide. But if you have a suspicion and there is clinical history of infection, especially parasites, so at this time, you have to go to the peripheral, to the tail of the slide, and even to the head of the slide, just to pick up this parasite because the parasite is a heavy organism. So while when you just when you smear the slide, it will keep either in the tail or in the head of the smear. And even when you are reviewing the slide for patients with severe leukopenia and you are suspecting, for example, leukemia or you are suspecting abnormal cells, so go to the edges and go to the head of the slide because again, while spreading, maybe these cells will be distributed or distributed in the edges of the slide, not in the body of the smear. Okay, yes, white blood cells is usually normal with absolute lymphopenia in COVID patients. Yes, because because sometimes COVID patients, you can see normal white blood cells with normal neutrophils or sometimes a high number of neutrophils, but the main player in the COVID patient is the lymphocyte, which is reduced. So the absolute lymphopenia, it can be corrected by the increase of the other cell subtypes like neutrophils, monocytes. Is there a special game? Yes, we can see increased granulation in patients using G-CSF. That's true. This is why I said increased granulation. So toxic changes, it's a terminology that is given for neutrophils that showing increased granulation, either due to infection or drugs like G-CSF. So but how we can use this word? We can correlate always. We correlate. So if you, while you are examining the peripheral blood and you see some neutrophils with increased granulation, you can easily say this is a neutrophil showing increased granulation or toxic granulation, likely due to G-CSF or growth factor therapy effect. And again, always correlate with the clinical correlation. So if a patient presented with infection, so it's mainly due to infection. But if there is no any signs or history of infection and inflammatory process, so again, you have to look after the reason behind this. And usually in G-CSF, not all the cells show increased granulation. And again, in G-CSF, you will find some immature cells in addition to the neutrophils. We can, can we see toxic granulation in hemolysis? Not usually. Again, toxic granulation mainly seen in infection process, inflammatory malignancy, but in hemolysis in particular, it's not it's not a part of the hemolysis unless if the hemolyzed patient, he also has infection or inflammatory process. Yes, any effect of the steroids on neutrophils? Usually steroids increase the neutrophils, but in the morphology wise, it may show some little changes, but not that much and not to the level of true dysplasia. You can find some abnormal or atypical morphology, but I don't think it exceeds 3% of the neutrophils or maybe 5%. This is why when we are reporting the dysplasia, usually we use a number of involved cells. So usually based on the WHO, any dysplasia above 10% is considered significant. But what if you have a dysplasia less than 10% or less than 5%? So based on the WHO, any dysplasia more than 10% is significant. However, if there are cases showing 5% to 10% dysplasia, again, you have to correlate this finding with the clinical presentation, with the clinical background, with the other lineage to start to see if the patient has abnormal blasts or abnormal cells. But if it's less than 3%, it can be seen in any condition, so it's not that much significant. Okay, next. Yes, in the eosinophilia, this is what I said, usually there is a big list of conditions and diseases that cause eosinophilia. So this is why any patient who presented with eosinophilia, just exclude the secondary causes before we jump to the primary causes. And again, sometimes patients with severe allergic reactions can show eosinophils more than 30%, but again, this is what I said, there is short-lived eosinophilia and prolonged eosinophilia. So prolonged eosinophilia, based on the WHO, it's defined as more than three to six months. So this is prolonged persistent eosinophilia that needs more investigation. But eosinophilia that is associated with parasites or severe allergic reactions, it's usually short-lived. It can disappear after you treat the primary cause. Type. Okay, so thank you for your attendance. So we just have extra four minutes. So hopefully, I gave you a simple, to the point white blood non-malignant white blood cell findings. So hopefully we can continue these courses in the future, and inshallah, tomorrow we'll continue this activity with Dr. Shukran. Jazeera. You.