Morphology Session 6

Yes, so today's session is a bit on demand because people going for FC part two exam, they have requested for certain specific Fs. Uh, they thought that they are having difficulty in differentiating between infectious mononucleosis, CLL and ALL. So the trick for the exam is that you need to focus on the history, and then on the presentation, and then on the cell count. So white cell count, a patient of infectious mononucleosis will always be a young patient, from 15 to 24. A patient of ALL will be a young as well, but his counts will be, um, 200, white cell count will be 200 or 300. Infectious mononucleosis counts cannot be 200 or 300 or 800. Their counts will be like 11 or 12, like that. CLL patients on presentation are usually asymptomatic. The films are usually from the GP film, or it comes with hemolytic anemia, and the counts are usually above 50 as well. There is, uh, quite a lot of difference between CLL blood cell, white cells, and the ALL cells, which you will see now. Yes, they do have some, um, cells which have some scalloping on the red cells, but it does not mean that this is infectious mononucleosis. Infectious mononucleosis cells have basophilic cytoplasm. They are few in number, not abundant like CLL. So we will see them now. So I would like to have a volunteer for the first case, please. Right, who wants to go ahead first? Yeah, I can go for it. Okay, all right. So this is a 24-year-old boy, yeah, who presented to GP because of fevers and some swelling in the neck. Okay. The full blood count shows white cell of 16, but the, but the BMS biomedical scientist called you that there are some abnormal cells which he thinks like acute leukemia or leukemia-like cells, and he wants you to review the blood film urgently. His hemoglobin is normal, and his platelet count is 150. So this is the power 10. So I will go through power 10 to give you a general overview. Yeah, so, um, at low power, um, I can see there are, um, increase in the white cell count, moderate increase, um, likely mature. But, um, I can't appreciate, uh, any lot of power. So you will go to 50, then to 50. Yeah, okay. So, all right. So starting with the white blood cell, um, uh, there is, I would say like atypical, um, like the ALL lymphocyte, um, with large, um, large cell compared to the red cell size, um, about the cytoplasm, um, with, I think the nucleus, it seems like, U, it's not like the condensed or compacted chromatin, it's more diffuse, but it's not, um, yeah, I can't appreciate nuclei. Uh, there are a couple of neutrophils, mature neutrophils. Okay. So how would you report this blood film for the exam purpose? Okay, um, I didn't comment on the red cells on the platelet. The red cells, um, it seems, uh, relatively, um, normal, um, yeah, there are few, uh, acanthocytes, um, and seems like normal platelets. So in terms of the report, I would say, um, there is slightly increased, uh, white cell count, mainly, um, lymphocytosis, and with atypical lymphocytes. Uh, no obvious blasts could be seen, um, preserved hemoglobin and platelet counts, um, and to exclude, um, to exclude, um, infection, mainly, infectious mononucleosis. Okay. So you have answered two, um, sections of the report. One is missing. You have commented on the film and what do you think is this film consistent with? BD, yeah. Um, the film is consistent with, um, reactive lymphocytosis, likely, likely lymphocytosis, I would say, um, in light of the history and age of the patient, um, infectious mononucleosis needs to be excluded. So we need further tests. Yes. So while reporting the blood film, I always comment on the, uh, cell line which has the problem. This blood cell, uh, the problem was in the white cell count. So comment on the white cells that this blood film shows lymphocytosis. Yeah, the white cells are atypical, mature with basophilic cytoplasm and prominent scalloping around the neighboring red blood cells. The red blood cells are normal with few, um, acanthocytes, you can say, or poikilocytes. They are very few, or if you say that the red blood cells are normal, that is fine as well. Yeah, the platelet counts are normal as well. There are no blasts. The most likely, uh, diagnosis or the blood film is most probably consistent with a reactive picture. To exclude infectious mononucleosis, um, the patient would need some further tests, um, like viral serology or Monospot test. So then, um, comment on the blood cell, your probable, um, diagnosis, and suggestion of further test. This will complete your report for six marks in the pathology exam. All right, okay. Then the next question in the exam would be for two marks. What are the, uh, set of investigations that you were likely to do? So this is the repetition of your, uh, section of blood report. You would do viral studies, hepatitis B and C, and HIV, Monospot test as well. And the third one, you can write as EBV PCR. Yeah. And then the last question would be, what is the most likely diagnosis from this scenario? So you can say the most likely diagnosis from this scenario is infectious mononucleosis or reactive lymphocytosis because the patient has fever, and he has lymphadenopathy, and he is young. He has reactive lymphocytes. There are no blasts. The count is only 12. Yes, and they have prominent scalloping. So most likely it is consistent with infectious mononucleosis or reactive lymphocytosis. So this would complete your question, and for sure you will get nine out of 10 marks in the exam. Okay, right. Yeah, infectious mononucleosis or reactive lymphocytes. The, it's very common in the short case of morphology. So try to collect the blood films, make your own boxes during practice, keep them for your, for the exam. Sure. Thank you. Now we have a second case. Again, a 24-year-old boy. I need a second volunteer for the second case. Yes, anyone volunteer for the second case? Yes, I can try. Okay, right. Again, this is a 24-year-old boy, and you have been called by the biomedical scientist regarding the blood film and the white cell count. The patient himself presented to, uh, ED in a confused state. The CT scan in the emergency department shows intracranial hemorrhage. The biomedical scientist noticed that the platelet count is very low, it is 94. The white cell count is very high, it is 960, and the hemoglobin is 102. He thinks that this film is consistent with chronic myeloid leukemia. So this is the general overview. This is the power 10. Okay, so I can see there is a leukocytosis on the peripheral film. Going to 50. Yes. Okay. You can start commenting or reporting the blood film. The first question in the exam would be, report the blood film for any short case and long case. They would say, report the blood film, report the dine, or report the aspirate. Okay. So, uh, WBCs are increased in number, and, uh, they are, these are abnormal, I think promyelocytes or blast, and these are atypical cells. These are small to medium in size with high. I don't know. I don't know what do you mean by promyelocyte or blast. Okay, these are atypical cells, uh, with, and these are immature cells with high N:C ratio, and there is scanty amount of cytoplasm which is granular, and the nucleus is somewhat open and cleaved. Few cells also showing cleaved nucleus, caving in nucleus, and these are small in medium size. And RBCs, these are most likely normocytic, normochromic, and platelets are reduced on the peripheral smear. Okay. So you have commented on the, um, cells. The film is most likely consistent with, consistent with, uh, leukocytosis, uh, most likely acute leukemia, acute leukemia. Okay. What next? So further investigations are required to confirm the, uh, diagnosis, like bone marrow aspiration biopsy, F or cytogenetic or, um, AML Rara, and, uh, flow cytometry to confirm the acute leukemia. Do you think this is an emergency? Yes, this is an emergency, and refer the patient to under the care of hematology and, uh, start the, uh, I mean, coagulation profile, uh, investigation for the coagulation profile investigation, and, uh, if there's possibility of the APL, so start the ATRA, and, uh, supportive measures. As there is already intracranial bleed, so this is for the bleeding. Why you think this is APL? Because I, like there is cleaving in the nucleus, and these are not in a good shape, and the patient is young and came with bleeding, and WBC count is high like this. These type of the cells, few cells are giving the appearance of dumbbell and butterfly-shaped appearance. So I'm not confirmed, but I'm just giving this as a suspicion. So you would say this blood film shows leukocytosis. The white cell count, the white cells have high N:C ratio, some of them have prominent nuclei with a granular cytoplasm. Platelet count is low. No platelet clumping seen. Yes, the red cells are normochromic, normocytic. The film is most likely consistent with acute leukemia, given the patient presentation and bleeding. This is a hematological emergency which needs to be assessed by hematology urgently, and urgent flow needs to be submitted for, uh, diagnosis and urgent hematology intervention is required, which is reducing the white cell count. This is not APL. The cells are not bilobed, they are not granular, they are not large in size. They are just a bit large than the red cell. And what, and APL would not come to you with 960, white cell count. So you cannot say whether this is acute myeloid leukemia or acute lymphoblastic leukemia on morphology. You can only say probably acute leukemia. The, the lineage differentiation is always on the flow. The flow will tell you whether this is myeloid or this is B or this is T, whatever the flow material. You cannot do bone marrow biopsy in this patient. He has a bleed, he has been, he is confused and unconscious with low GCS. So it's very difficult to do invasive procedure in a patient like this. Okay, right. Why the patient has intracranial hemorrhage? Because of leukostasis. What the leukostasis will do? What the high white cell count will do to the bleeding? Easystasis produces, uh, blood flow obstructions, or maybe increases the permeability of vessels, so it produces intracranial bleed where the resistance is high. Okay. So when the white cell count is high, the red cell count is high, or the platelet count is high, they consume the von Willebrand factor, and they can produce acquired von Willebrand disease, which can make the patient prone to bleeding. So you may have seen acquired von Willebrand disorder with polycythemia, with essential thrombocythemia, thrombocytosis, or in a very high white cell count, they consume the von Willebrand factor and multimers, leading to intracranial hemorrhage. But in this case, the patient also has a thrombocytopenia, which could also cause intracranial hemorrhage. Yes, it is 94. I think I mentioned the, what the platelet count is 94. So, yeah, so not that much to cause, uh, bleed. But on smear, they don't seem to be 94. Yes, these platelets are, uh, few platelets are visible. So this is, uh, 50x field. So you can see multiple here. So Dr. Ahmed, this patient would need, you said he also needs a hematological intervention. As you said, we cannot define the lineage on the basis of morphology. So as these cells look like ALL, do we say to start the pre-phase steroid? So what intervention do we advise if we are not sure about the lineage of these atypical cells? What do you think we should do in this patient to reduce the white cell count? Usually, if we are suspecting ALL, so you, you start the pre-phase steroid and also cytarabine. But usually, if it's AML, then we can also start do the cytoreduction with hydroxyurea. But I'm not sure what is the protocol in the UK and what they do. So he came with a bleed, threatening bleed, and the white cell count is 960. We did leukapheresis for consecutive two days and reduced his white cell count from 960 to 100. Question is that, if you are not confirmed that this is ALL or AML or APL, because we are not sure about the still abnormal promyelocytes. So leukapheresis is contraindicated in that case. Yeah, but this is not APL. APL has typical bilobed nature. I think I need to bring out the APL in the next session as well, and they don't have cytoplasm like this, small cells like this, or high white count like this. But hypogranular variant can be seen like this. I have seen so many cases of APL. They usually come with pancytopenia, and hypogranular usually come with hyperleukocytosis, but it would be 30, 50, 60, not not 900, not 700, not 500. Okay, you have mentioned the things in reverse order. Hypergranular present with pancytopenia with low TLC, and hypogranular variant, it presents with high TLC, and vice versa. And one more thing, is there any cutoff for which you will advise the leukapheresis? It depends on the patient's clinical presentation, because the chemotherapy will reduce the white cell count slowly. We need a quick reduction in the white cell count in this patient because he has intracranial hemorrhage, and that would continue to increase if you do not intervene quickly. That's why we did leukapheresis in him and reduced his white cell count to below 100 in two days. If there is some delay in arranging the leukapheresis, can we start the hydroxyurea? Even if it's, yes, you can start, but ideally, all the ICUs here, they are equipped with apheresis machines, so we do not face such, uh, things here in reality. Okay. So the last question in this patient would be the risk stratification. What are the high risk? What are the poor risk factors? And what are the standard risk factors? If it is, supposed to be ALL, then age, gender, counts, cytogenetic, no, not like this. I'm asking you, what are the high risk factors in this particular patient? High TLC count. Mhm. And he's a boy. I think yes, he's a boy. And intracranial grade is also a risk factor, and intracranial involvement. Yes. So always read the question. What is asked from you? Sometimes the questions are general, and sometimes they are asked about this particular person. If I have asked you a general question, it would be a different answer. I have asked you about this patient, it would be a different answer. Okay. Can we discuss the W of this case? ALL W on this case? Yes, the other W question, they would ask you, what are the close automative markers for B and T? Then, then the next question would be, what are the general high-risk factors in a patient with acute blastic leukemia? And what are the standard risk factors in a patient with ALL? Then, what is the immediate management of this particular patient, which we have discussed? Then, what further investigation would you like to do? Which would include coagulation profile, fibrinogen, if the patient is settled now, then bone marrow biopsy for karyotyping, cytogenetics, and flow cytometry and molecular mutation. Then, the next question would be about the management. So you have to explain the diagnosis to the patient based on the bone marrow biopsy result and discussion regarding the treatment. He is a young boy, so in the scenario, did not mention to you anything regarding his comorbidities, so you have to, um, discuss the different treatment options or trial if available in your hospital, patient wishes, his religious belief, because he would need blood transfusion, information lied to the patient, CNS contacts to the patient, and discussion in MDT as well. If, yeah, sorry, go on. So if you have a trial open in your hospital, which is open in all UK hospitals, that is the ALLtogether trial. It's a new trial in young patients for less than 25. You can enroll the patient in the ALLtogether trial if the patient agrees. If not, then you can give him any, you call, um, treatment which is the, you call UK14, usually if the patient is Philadelphia chromosome positive, but we enroll this patient in ALLtogether trial. Then the examiner would ask you about some side effects of the chemotherapy drugs, because ALLtogether or the UK ALL protocols, they include methotrexate, asparaginase, vincristine. Any common side effects with these medications or any antidote of these medications? And for the side effect, then MRD monitoring of the ALL by flow or by mutation. And then, what if the patient relapses? The ALL patient relapses, what would you do? Then you have the option of BLAM or another. Now we have started CAR T-cell therapy for ALL as well, but I don't think they would go into detail. Indication of CAR T for a patient with ALL, but they would discuss the third line of therapy if the patient does not respond to, sorry, before that, they would ask you regarding the BLAM or worse effect or side effects. So in BLAM, it's anti-CD22, and it causes, it causes VOD, while in BIL, it's a continuous infusion therapy for few, for few weeks, and its side effects are neurotoxicity and sometimes affect the CD19 population as well, making the CAR T a bit difficult. And then, if the patient relapses again or refractory to BLAM or another, what are the options you have? Either ALL grafting or CAR T, depending upon which one is important. So the W question will start from a case scenario like this patient presented to ED with intracranial hemorrhage, and BMS was concerned regarding how high white cell count and leukemia. Then the examiner would ask you, what do you suspect? He may give you a paper with description of blood film report, so you can have an idea that this is going towards ALL. Then when you say that you do further investigation like flow cytometry, he would give you flow cytometry to make your diagnosis. Then he would ask you regarding prognostic factors, which include multiple mutations and translocations. He would give you a paper which would say Philadelphia positive or negative, Notch1 positive or negative, MLL or PBX or 9;22. All of this information will be given. So he will provide you piece of information as you go forward. He would not keep everything in front of you at once. So you would take the case with him like this, and then investigations, then a discussion with the patient regarding management, choice of therapy from the patient. They would not ask you about the detail of any protocol like what drugs are involved in ALLtogether, how you will give, what is the dose. No, nothing would be asked like that, because you have only 7 minutes for one question in the W, and they want to ask as much questions from you in the W as possible, like they want to take the question from the beginning to the management to the end. So they would be quick as well. So these, there is no protocol running in your trust, and will you offer this patient UK14 or 12? So our hospitals, all of the hospitals in UK, they have the ALLtogether trial running on for the young people less than 25. If not, then the patient is transferred to a tertiary hospital where they can give a trial to the patient. The previous trials are a bit old. The ALLtogether trial is a new one, and all the young patients, if they are eligible to enter, they are enrolled in them. So do we have to go through this trial? No, no, no. I asked you that if you open the ALLtogether trial, it is 496 pages of protocol, so no one can read it. Yeah, so just remember who can enter into the ALLtogether trial, who can enter into UK ALL14 trial, who can enter into UK ALL19 trial, who can enter into UK ALL60 trial, and that's fine. So we need to know the exclusion and inclusion criteria. Yes, a bit like, um, ALLtogether trial in UK, I think it is from, um, 0 to 25 or 0 to 29 years age in UK. Double check the 25 or 29 age, the upper limit. The ALL should be a new diagnosis. It should not be a refractory or relapsed one. Patient should be able to consent, and patient should be a resident of UK. And if it is in a case of female, she should not be pregnant. And exclusion criteria, as I mentioned, it should not be a relapse case, it should not be Philadelphia chromosome positive, and, um, the age criteria, the patient should not be above 29. In other European countries, the age limit is high, but in UK, I think it is either 25 or 29. What does this mean? The patient should be able to consent. If you are including 0 to 25, so this doesn't make any sense. How come a three-year-old or a five-year-old child consent? So for a three-year-old patient, the parents would be consenting for them. Does this mean the patient should be able to consent? Yes, this is for the adult people. After 16, you can consent in the UK. Before that, the parents can consent. If the patient is unconscious, usually it is the parents who are involved in the consenting procedure. So this protocol is applicable to pediatric population as well. Yeah, all right, okay. So a third case, who wants to go ahead? The third one, I can try. So this is a 58-year-old male who went to GP for routine blood test, and the GP noticed that the white cell count is high, 76. And he asked for the blood film of this patient. Then the biomedical scientist or the lab scientist called that he is seeing some abnormal cells in the blood film which looks like leukemia. So this is the power 10. On power 10, it seems to be a high TLC count. Okay. Power 50x. Yes, you can start commenting. So the blood film shows leukocytosis with predominant population of mature looking cells which are variable in size and have irregular nuclear contours. They have high N:C ratio and their nuclear chromatin is condensed with no prominent nuclei. And some, and the neutrophil count is also preserved, seems to be preserved. There are also M cells on the smear, and the RBC morphology seems to be normocytic, normochromic, and the platelet count seems to be low normal. The blood findings are most likely consistent with a lymphoproliferative disorder and would like to confirm the findings by flow cytometry on peripheral blood. Okay. So the flow result: the patient has CD5 positive, 23 positive, 43 positive, 200 positive, and it gives you a diagnosis of chronic lymphocytic leukemia. Do you want to treat this patient? As he's asymptomatic, you would like to carry out some further investigation like test of hemolysis to rule out any underlying hemolytic process going on, and also you will do the LDH, the serum protein electrophoresis followed by immunofixation, and then you want to do, you will also ask for bone marrow biopsy and will do the cytogenetics, some molecular genetics like TP53 mutation or IGHV mutational analysis. And if the patient is asymptomatic, you just observe the patient six-monthly for the first year. Okay. So you mentioned that you would do bone marrow biopsy. If TP53 mutated and IGHG unmutated, would you treat this patient if it's asymptomatic and his TLC and his TLC count or his lymphocyte doubling count is static, then I will not treat him. I will just observe him six-monthly. Why do you want to do bone marrow biopsy then? Because when I want to treat, so I would have the baseline bone marrow and to have the assessment of tumor burden assessment, whether it's a diffuse involvement or there is any nodular involvement. If it is B involvement, he would have complications. This patient does not have such opinion. On first instance, I will not go for bone marrow. You want to say this, his count is slightly high, he is asymptomatic, he needs monitoring only till he develops any constitutional symptoms or any increase in the counts or any anemia, splenomegaly, any lymph node that is compressing the nerves or blood vessel, then you would think about treatment. He may continue with this level for 10 years like this. His blood counts may be 20 or 30 or 50 for 10 years. When we do bone marrow biopsy and if there are cytopenias, if we know this cytopenia is due to, due to a hemolytic process, still we go for bone marrow? Yes, if you are planning, if he has any indication of treatment of CLL, then you decide to do the bone marrow biopsy to find out the TP53 mutation, to find about about the Notch1 status, SF3B1 mutation, or BIRC3 deletion, 13q status, deletion 11q, trisomy 12. All these, and it would also tell you about the, um, involvement, the degree of involvement of bone marrow as well, if you're planning. Okay, Dr. Amar, if a patient developed cytopenia, not due to the hemolytic anemia or not due to the autoimmune process, but due to the infiltration, then is it an indication for the bone marrow biopsy and treatment? Because cytopenia is itself an indication of, uh, treatment of CLL. A patient would be staged as Binet C. And if you read the indications of CLL treatment, one of the indications is the cytopenias. Yes. Then, then you would need the, uh, the prognostic stage of the patient, for which you need multiple tests like TP53 loss or mutation, multiple molecular mutations, find out whether he is of bad prognosis or standard prognosis, and then you would decide regarding the, uh, treatment drug. Although almost all of them are same in terms of, uh, treatment, like for TP53 mutated and without mutated, but the difference is of the ibrutinib. You can give ibrutinib only if there is TP53 mutation or deletion. Even if he's asymptomatic, still we go for further investigations as a routine workup? No, no. We don't do any investigation if the patient is asymptomatic and he's not requiring any treatment. We just monitor them as you mentioned, six-monthly. Yes, for six-monthly, we monitor him to keep an eye on his lymphocytes. And you find out he has CLL, but although he's asymptomatic, but you won't do the rest of the workup, the test for hemolysis, the LDH, the immunoprotein electrophoresis, or the immunofixation. You don't want viral serology. You want to go for them, or and other organ involvement. If the hemoglobin is normal, why I would do hemolytic screen for the patient? And what about the staging? You will, you do the CT scan to find out where there is any abdominal or mediastinal lymph node involvement. If he has lymph, if he has lymphadenopathy, he would have constitutional symptoms as well. He would have night sweats, weight loss as well with that. If let's suppose he's stage B, you want to do the staging at his diagnosis. A staging CT scan, you mean? No, like we stage the patient based on R, whether there is only lymphocytosis or there is only lymphadenopathy. Sometimes the lymphadenopathy is occult, you cannot find it on the physical examination. To find out whether what is the stage of the patient, although he is asymptomatic, you want to do these investigations. Staging CT scan would be done. Yes, I agree with that. But if there is pancytopenia, if there is any cytopenia, if the hemoglobin is less than 100, cytopenia is less than 100, then he is already a stage three, sorry, Binet stage C. So any pancytopenia in the CLL patient needs treatment. It means his bone marrow has been involved. It means the stage A doesn't need any CT scan at the diagnosis. If the asymptomatic stage A patient, you don't need any CT scan for the diagnosis. If you have uncertainty about the diagnosis, then you can only do the lymph node biopsy, as I remember from the NCCN guidelines. So Binet stage A is if there are three lymph nodes or less than three lymph nodes. Then stage B is if there are more than three lymph nodes involved. When C, if there is any cytopenia. So lymphadenopathy can be palpable or it can be not palpable. Lymph nodes may be in the mediastinum somewhere. The staging CT scan will tell you where is the lymphadenopathy and how many lymph nodes are there, the staging. So that's the question, do we do this staging CT? Yes, staging CT scan is done for every malignancy, but not other investigations like you mentioned hemolytic screen. No, if the patient is not cytopenic, why I would go for a hemolytic screen? If the patient is not cytopenic, why I would do bone marrow biopsy? For you, just need monitoring six-monthly. Okay, got it. Thank you. Okay, if cytopenia developed, it means his bone marrow is now involved. He would need the, uh, bone marrow biopsies and all other investigations, and because you are planning a treatment for him, right? Yeah, thank you. Excuse me, I have a question, please. Yeah, yeah. Just back to the morphology of this film. Um, I know that with the history and with the counts, like it looks like, um, CLL, but it, the cells for me, like it was mature lymphocytes, but there was a bit of, um, pleomorphic appearance. So like, it's not, not always like should not be monomorphic appearance for the T? No, in CLL, there is no monomorphic appearance. Okay. If you see the blood film of five CLL patients, there would be some difference in the, in the cells' appearance. Yeah. As you go towards the thicker side, the cells would become more smaller and smaller without any cytoplasm. As you go towards the thinner side, toward the tip, the blood cell, the white cell will become bigger in size with more cytoplasm, but clear cytoplasm. All right. So to have it would be expected. Yes, because in CLL, you can expect some degree of prolymphocytes as well. Yeah. So if they are less, they are usually less than 15%. They are bigger than the usual CLL cells, but they have a prominent nucleus as well. Yeah. Okay, all right. Thank you. Let me check if I have another film of CLL. So this is also a CLL blood film, and you can see it is a bit different than the previous one. Here the cells become open as you go to the thinner side, the cell size a bit increased. Yeah, but the nucleus is very mature, dark color. As you go towards the thicker side, they start to get shrink in size more and more, and here they appear just like the same size of the red cell, almost with, yeah. And, um, yeah, thank you. So like, because sometimes, like it could be also, you know, with the mantle cell lymphoma, because this is the mantle is characterized by the characteristic, it would be like pleomorphic. So yes, so mantle cell lymphoma has five different subtypes according to the new guidelines: small cell variant, marginal zone variant, pleomorphic blastic variant. There is one more as well. That's why we say in reporting the blood film, most likely or probably consistent with MCL, mantle cell, or follicular lymphoma. We cannot make a diagnosis on the blood film. That's why you always suggest in the third part of the report that you need to do flow cytometry to confirm the diagnosis. And once you do the flow cytometry, you will have a clear picture whether this is CLL, this is, uh, mantle cell, or this is something else. Sure. We have a blood film of a patient which was, um, just like an ATL, a clear pleomorphic shaped cells of the patient, and everyone from junior to senior to consultant, even mentioned that this looks like ATL. But when the flow results came back, it was CLL. Yeah, I had posted the picture of that case in the, in our LinkedIn, in our Facebook group as well, with a comment that do not, uh, make a diagnosis on the blood film. You need investigations like flow cytometry, biopsy, cytogenetics to confirm a diagnosis. Sure. Yeah, okay. Yeah, thank you very much. Sorry, Dr. Rahir, in this CLL case, in further investigation, we only advise flow cytometry. We still say we need bone marrow biopsy or cytogenetics. Flow cytometry, bone marrow biopsy, and cytogenetics, you would do only if there is cytopenias or you think there is B involvement, or you think you need to treat this patient. It's more safe to report always and a bone finding consistent with LPD, and we should not comment on the immunophenotyping unless and until and unless we have the flow report. Yes, so in the, in the exam, if the flow is given to you, then you have to say the flow is consistent with this diagnosis. If flow is not given to you, then you would say most likely this film is consistent with this diagnosis. I need further investigations like flow cytometry or bone marrow biopsy if it is a leukemia to confirm the diagnosis. Okay, on the blood film, you cannot make a diagnosis, even if you have an APL blood film, you confirm it later with the PCR or bone marrow biopsy. All right. So the last case, who wants to go ahead? Anyone? I can try again. Okay, this is the last case for today. Uh, this is an 18-year-old, um, female who is an immigrant to the UK, and, uh, she was referred by GP to us because she's feeling very tired and lethargic. She was on a transfusion program back in her home country, but she does not have any files with her or any cards with her to tell you what was the diagnosis. Her blood film is in front of you. Her hemoglobin was 52, so she has been transfused as well. MCV is 71. Platelet count is 142. White cell count is 4. This is the blood film. What do you suspect this patient has from the history? It seems to be she has some hemoglobinopathy, that's why she's on regular transfusion, and her indices are of microcytic hypochromic. Okay, so report the blood film, just like you would do for the exam. Okay, the RBC morphology shows, um, or blood smear, along with anisocytosis. There are tear drops, there are microcytes, hypochromic cells. Mhm. All right. The blood film is consistent with, uh, right. Some on the basis of his, I'm not sure what should I say. It's consistent with maybe I couldn't find any NRBC. There are no basophilic stippling. Mhm. So we had a film like this in the exam, and they asked us, write down six findings. One is microcytosis, anisocytosis, poikilocytosis, teardrop, microcytosis, hypochromia. No NRBCs, no basophilic stippling. Hemoglobin indices are, uh, hypochromic. There are even no target cells in it. Okay, all right. Did you see any Howell-Jolly bodies in this picture? Or? Not, yeah, there were cells. This, yeah, and target cells as well. 1:00. Okay, right. So you can expect such questions in the exam as well. Right, write six points because the report is six marks, so they asked us to write six points in this blood film. Okay, right. What further tests you would like to do? Tests. Yes, this is the blood film. The patient is anemic, microcytic. The blood film is in front of you, and, uh, the patient does not know the diagnosis. She is an immigrant to the UK. She has been transfused, but we need a diagnosis for this patient to bring her under our NHS services. If she has any hemoglobinopathy, I would like to ask for the test of hemolysis along with the HPLC and the parents' both parents' CBCs and their HPLCs. I'm, if this patient has been recently transfused, then HPLC would not be of much help. Okay. So this patient has been transfused in the ED because her hemoglobin was 52, and she was symptomatic, tired, short of breath on exertion as well, so she has been transfused. Okay, all right. So you would like to do, um, uh, HPLC, FBC is in front of you, and then, uh, if there is hemoglobinopathy, would you like to confirm that on a second test as well? Yes, hemoglobin electrophoresis. You can make a diagnosis of hemoglobinopathy if there are, uh, two tests are positive, different methodology. Yeah, then the patient's mother gave you an HPLC, that this HPLC was taken 4 years ago. Years ago, so there was a peak in the S region which accounts for 7.8%, and another in the A region which is 18.4%, I guess. So S is more than A. We ignore the A2 peak in the presence of S peak. These HPLC findings are more consistent with sickle cell beta plus thalassemia. And her indices are also microcytic hypochromic. There, she's more consistent with sickle cell beta plus thalassemia. Yeah. So can you explain to the audience again how did you make a diagnosis of sickle cell beta plus thalassemia? On the basis of HPLC, and why it is not sickle cell beta-null? Because if it is beta-null, so they would not be any A peak. And I, the other differential is sickle cell trait, because it also has an A peak and S peak, but if the S peak is more than A, then it is more consistent with sickle cell beta-thalassemia. If A is more than S, then it is more consistent with sickle cell trait. Usually in sickle cell trait, we have 60% adult hemoglobin and 40% sickle cell hemoglobin. But if this ratio is reversed, then it's compound sickle cell with beta. And also the RBC indices of the patient will also help you to confirm this diagnosis. Usually sickle cell anemia is normocytic, normochromic. But whenever there is microcytic hypochromic indices, your differential will include sickle cell with beta, sickle cell with alpha, or it could be iron deficiency with sickle cell. So if A2 is above 5%, then you call it as beta plus. If A2 is less than 5%, you call it as A2-null. This patient has 70% sickle cell hemoglobin, 18% of A2. It becomes sickle cell beta-null. One possibility. If it is not A2 and there is only sickle cell and A, then there is a possibility of sickle cell trait. Patient has received a transfusion, but this is an old HPLC in this patient's case. And if it is sickle cell beta-null, you would expect NRBC in the blood film as well. All right. So this, yes, this is a case of sickle cell beta-plus thalassemia. Sickle cell beta-plus thalassemia. And if it is a W case, in W, they would ask you about the principle of HPLC. They would ask you about how would you assess a new immigrant patient in your clinic. So you would write all the details from A to Z, from checking the vitals to enrolling him into the hemoglobinopathy services. There are new guidelines in the BSH regarding thalassemia and hemoglobinopathy, and HBE has summarized that in 101 points, what you would like to do in a hemoglobinopathy patient when you are enrolling it into the services. Or I would advise you to see the annual clinic letter of a thalassemia patient or sickle cell disease patient. It has all the required information that we usually ask from them and that you need to mention in the exam. Then the other W question would be regarding indications of chelation in in such patients because they are usually transfusion dependent. When would you start iron chelation for them? Then next questions would be, what are the different drugs that are used for iron chelation? And then what are the side effects of these drugs? Because this patient is young, she is planning pregnancy, or she came to your clinic on next visit with 6 weeks of pregnancy. What would you like to do now? Or they can ask you regarding the complication, acute complication of sickle cell disease or chronic complication of sickle cell disease as well. So sickle cell disease can be a 7-minute long question. In general survival and the new treatment for sickle cell disease, the exa-cell therapy for the sickle cell disease, which has been approved last year by NICE. You just remember the name that you know you are aware of this new therapy, and that's it. Sorry, which one? The exa-cell therapy for the sickle cell disease patient. It is mentioned in the HBE. So why don't we find any sickle cells or both cells in this case? Because of the transfusion. Transfusion. And she's not sickling at the moment. That's why she may have, she may have, yeah, she may have concentration in iron deficiency as well. But at the moment, she does not come with any sickle cell pain or anything else like that. And the HPLC was an old HPLC. If it was a new HPLC, it would not be like that. Can you focus any Howell-Jolly body? This is a small one. Let me check more. From one, this one. Can be. Let me check more. So how would we report this case in exam if we are not, if we are not given the HPLC, and there is only microcytic hypochromic cells, and the history is suggestive of some hemoglobinopathy, but we are not sure what it is exactly, but it seems to be iron deficient picture more. So just like the other blood films where you commented on the red cells, white cells, and platelets, and then you give, you are suspected that most likely consistent with, and then you suggested further investigations. Like, no, I'm, I think in this case, what would be our most consistent suggestion? What would be your suggestion? HPLC and electrophoresis. These are the two. No, no, these are the two tests. The findings are the main diagnosis. What is that? I did not get your point. I said there is microcytosis, hypochromia, although I couldn't find any NRBCs or, um, basophilic stippling. Although the history is consistent with some with presence of some hemoglobinopathy, but my this blood picture is not consistent with any of the. I cannot say whether it's a sickle cell trait or it's a sickle cell disease or it's hemoglobin C disease or it's just iron deficiency. So what would be my conclusion in reporting that these findings are consistent with iron deficiency? So you would say, the blood, this blood film contains microcytosis, hypochromia, multiple target cells, Howell-Jolly bodies, plus transfused red cells as well, or you can see dimorphic picture in the beginning. The white cell count, platelet counts are normal. The most likely, um, the blood film is most likely consistent with a red cell hemoglobinopathy or iron deficiency anemia. We mentioned teardrop cells as well. To find out the exact diagnosis, we need iron studies for the patient and, um, HPLC. So if HPLC is positive, then you will go for electrophoresis and genetic test. Thank you. Yeah, as, as this patient has recently been transfused, still we ask for HPLC or electrophoresis in transfused cases. It is a bit difficult to find out the exact diagnosis, but you can send the blood for electrophoresis even, or wait for some time to make the diagnosis. But in exam cases, um, they would generally ask what are the investigations for the diagnosis of hemoglobinopathy. But you need to remember that you need to confirm the diagnosis on two tests, not on a single test, because if I send genetics for this patient, it will take a lot of time. Okay, all right. So this was our session six. These sessions are free. I'm not going to monetize it. So I will request for donation. Thank you for those people who are donating me. And then please subscribe to our Hemato More channel. It will encourage us. And in the last, thank you very much. See you next week. Take care. Bye-bye. Thank you. Thank you. Thank you.