Transcription
Hello everyone. Can you hear me? Hello. Can you hear me? Yes, we can.
This is the first case and this is an 80-year-old female with anemia. Don't spending any since many months. Vel count and the pickax are normal. This is power 10. No power 50. Anyone who can come in on the blood or report the blood. Aisha is the first on the list. Can you hear me? Um, Godwin. Yeah. Yeah. This is an 80-year-old lady with persistent anemia since human with normal plated count and normal white cell count. Okay. So the blood. Okay. Sorry. You saying something? No. If you can report the blood fil please.
Okay. So this is a blood film showing um anocytosis. Um, they are microytes. They are microites although I've not seen lymphocy to compare but looking at the sizes they are different sizes. Um, they're also different shapes. I could see some fragmented red cells. Um, there are some achinosites. Yeah. And then the white cell appear a bit reduced on film. I haven't seen enough white cells on this film. And the platelet platelets platelets appear liquid on film. Okay. Can I see the white the lymphocytes or neutrofuse so as to help with my diagnosis? This is an inite compar. Okay. Okay. So I can see one of the lymphosyes they look clipped clipped in sites. [Music] So what is your impression? You have reported the you have commented on the cell line. What is your impression now? Okay. The history again please. I mean if it could help because I haven't seen anything. Yeah. So this is 80 year old female patient with persistent anemia since few months with normal white cell count and platelet count. Okay. So I can see pencil cells there and there are some fragments. Uh um the neutral field doesn't really look this plastic because with the age and the history I'll be thinking of possibly an MDS what neut looks okay looks okay so that's what I'm saying it's only the anemia Yeah, I mean with with the fragmented cells I mean I'm thinking of a hemolytic anemia. That's what would be on my mind because for the other cell line nothing really stands out to help me clinch the diagnosis. Mhm. Okay. So this is hemolytic anemia that is correct. So there are polychrommesia there is fragmentation. Patient has anemia as well. So you are suspect your impression is hemolytic anemia. And what is your suggest suggestion to the team because they may contact you later on. This patient has persistent anemia. What should we do? Yeah, they will have they will have the same thing in their mind. Maybe is this MDS or something else. So when you report the blood film in the exam, you will write comments on the cell lines your impression and then your suggestion as well. Okay, this can be or this can be a film from the world or from emergency. Okay. So if I'm thinking of first of all I would need to do uh the hemolytic screen. So they need to check LDH um retictolobin and they could also need to check um that direct antiglobin test and then um the hemolysis as well could also be due to infection although this has been longstanding. So they could also check for C reactive protein and also based on the history if infection is uh it's likely um as this is since there's anemia I mean first we could also want to exclude hematinic deficiency I mean just for completion um ion B12 folate Um yeah, I think based on the results the um the investigation result that would inform the next um the next test that will be done. Yeah. All right. That test is negative. B12 folate is normal. Infection is negative. What are the defensive diagnosis other than these? Okay. So for this patient if that is negative and all of that because of the fragmented cells I'm seeing uh cons also the age could it be so patient have other causes of hemolysis thing microangopathic hemolytic anemia uh like can patient have um metallic half valve could possibly be causing hemolysis of the red cells that's what I'll be thinking No patient have um any valular heart disease? Yes, you're correct. This patient has metallic heart and it has become dysfunctional which is leading to isolated anemia in the patient. Okay. In elderly patient if there is anemia always keep uh metallic heart well or mechanical hemolysis in your defense. If they say the renal function is okay, liver fun liver function may be slightly abnormal in himsis and that test is negative. Better folate is normal. Patient is not uh infectious then yes then the only suspicion is that this patient may have a clinical. Okay, this patient has mechanical hemolysis because of which uh the patient has isolated hemolytic nonimmune. All right. Okay. If you're appearing in FRC scenario.
Okay. All right. So this is a 56-year-old man with large eximator patches on the on both the elbows and on upper back. The GP had prescribed some cream and anti-allergics but the patient is not responding to antihistamine. The blood test shows hemoglobin of 110, white cell count of 16 and platelet count of 180. This is the blood print because the white cell count was high and is slightly low. The biomedical scientist can make the blood for you. This is power 10. A general overview. And now I will go to Oh, All right. Anyone who can start reporting the blood then The Lord 100 power sah Ali is next on the list. Hello. Hi. Yeah, if you can please report this blood for us. Yeah, I think there is abnormal infiltration with atypical uh lymphocytes which they are medium to large uh in size with the high NC ratio colum uh chromatin. I thought the earlier one it look like there is some the nucleus looks like. Mhm. with mature neutrils normal or slightly increase platelet count. Okay. We need a report from you. Yeah. So uh there is the uh in there is luccoytosis mainly lympho atypical lymphocytes with mature cytolast medium to large size with m sorry with mature nucleus medium to large size cryfor nuclei normal platelet count and remarkable red cell morphology. The film is suggestive of uh lymphop proliferative disorder and I would like to correlate with flowcytometry. You would suggest flowcytometry in this case? Uh yes. What type of LPD you are suspecting? B or T? T sound T sound. Okay. What you would do to find out the coronality in this patient? Uh usually we'll do uh TCR uh G rearrangement for alpha beta or gamma delta. Okay. What is your suspicion that what it can be? Uh given the history of eczema, I'm thinking about the scissor scissor syndrome. Okay. Yeah. All right. This patient has a refractory eczema not responding to the anti-allergics or anti-histamine and few of the cells that we have seen has deform nuclear. So this is hinting toward the type of LPD scissor syndrome. How do you treat it? Uh I think usually we will give u uh chemotherapy. Mhm. And and consolidation with autotogus stem cell transplant. Anything else? Is there any photo? Okay. Yeah, I think yes they usually receive photoesis. Yeah, they we receive photoesis from NHS DT and the refractive cases. Um we are discussing MDT for possible drug right is there any specific immuno phenotype markers for uh cizer syndrome I think it's usually uh CD4 positive but none is specific it will be CD2 CD3 and also CD5 positive and CD7 negative and usually CD4 positive, CD8 negative. So I'm trying to find out an ID and scissor cells for you guys, but earlier we have seen one. Yeah. Um but there are not usually so many means cerebilum like brain cerebelum or cerebrum. This bre has two or three that is typical of um cerebrum brain cerebrum but no they are not maybe this one if they have given you full blood count result in the exam scenario with high count. First of all, always check it at power four. Okay. And if it contain any uh travel history, the scenario contain any travel history, then checking at power four is must. There may be a parasite somewhere in the exam. Einophilia high einaphil count means um either this patient has some parasite somewhere hidden or this patient has cizy syndrome. The the scenario may not be as straightforward like I give you that this patient has refractory um eczema. They may tell you that this patient has abnormal full blood count is high. So always look at power four first to see if there is any parasite or not. Normally in Nicholas blood pin there are a lot of parasite. You cannot miss it. But in exam setting there is only one parasite in the whole blood pin. So you need to check it carefully. uh when whenever there is high einaphil count in the fullback count and if you fail to find any uh any parasite then go for um finding a scissor cell. They are more likely like this one with a lot holes and curves in their nuclear material.
All right. This is another 60-year-old patient with progressive anemia. The scenario in the exam is very small. They are very small scenarios and you will feel that all the scenarios look the same. This is for power 10. and make this power 50. Anyone who can comment on this blood or report the platform. you're next on the list. Yes. Um so um there is um red cell anupilocytosis with multiple with polychrommesia occasionally the spherosytes and multiple cytoides seen. Mhm. Also there is um platelet looks reduced in number nils um looks reactive with occasionally um lifted as well this nucleated red cell. So I should add a a further piece of information. This patient has a background of breast canc. Yeah. Um so um in the context of breast cancer so there is evidence of hemolysis with multiple cytoides and low platelets which in keep with micro andopathic anemia. So if patient has active cancer or on treatment it could be cancer associated maha. However we need just to check Adam 13 to confirm which is which liquid counts are normal. They are not low. They're not that doesn't look low. Maybe in some Okay. Sure. Usually with um cancer treated maha we treat underlying the under the line cause rather than treating maha. Yes. So the blood film contain a lot of and isopropate to theocytois detail like some poly chromatic cells, some fman uh teardrop cells, nrbc there are myocytes here as well. Yeah. And few of the neutrals were displasting as well. What would you call this? Um I think neurist. [Music] Is it a liquid or a plastic picture? It could be liquid or plastic picture. We saw the tear drops and the the left shifted and nucleated red cells as well. Yeah. So yeah, maybe the breast cancer is infiltrating the bone marrow now. That's why we have teardrops, we have NRBC and we have my as well. We have lucidlastic. Yeah. What are the different causes of lucidroplastic picture? Umlastic picture it could be with severe infection, it could be with bul stress, it could be with myop fibrosis as well. Okay. And bulertation by solid malignant. Yeah. All right. Remember the differentials of liquidic picture they usually appear in exam. [Music]
This is another patient 60 year old with anemia. Today all the things are related to anemia. This is for And this is I Anyone with any thoughts about this lecture? Sorry. No What happened today? All the people are silent alashi. Yeah. Um okay. So there's anemia with um anoglycolicytosis um multiple um teardrops iptoytes and target cells and red cell fragments thrombocytoenia. Mhm. Um I haven't seen a platelet clumps neutrfils appear morphologically normal normal granulation and nuclear lobulation. Um so I think any anemia with significant ancytosis as I said teardrops and thrombocytoenia I think that picture is suggestive of um probably micro fibrosis although I haven't seen any mature um sites Is there any other features in the red or not? Um, there is a polychrome here. Um, I think it's some stereotypes. Is there any hypocchromia in these red? So there's dual population of cells I think. Yeah, this the small hypochromic cells and the well hemoglobinized normal size cells. Are there any how? Yeah, I think I saw I saw one how jelly bodies and then I uh yeah, I can see two now. All right. Those features of hyposkinism. Um. Oh. So what what are you talking about? So um so with the target cells hypocchromic microitic cells and the hilly jolly bers these with hyposinism or Um not sure if this is hemoglob don't feel it's going with hemoglobinopathy. I feel like it could be mild fibrosis with massomally. Okay. So your impression is likely milo fibrosis and what would you suggest? So I would um want to um see I do I would suggest that I would do I want to do further investigations um send for driver mutations Jack to call RMPL and PCRL and um we do abdominal ultrasound for splenomegali and then bone marbio Y okay. What is the diagnostic criteria for myop fibrosis? How would you confirm that this is Milo? Sorry for the background noise. Um, so the um criteria there's major and minor criteria. So you have to have at least the three major criteria with one of the minors. Um, so bone marrow um medicalic proliferation and atia um and presence of driver mutation jack color or um mtl and um not in keeping with other myoid mal malignancies. uh the major the minor criteria is spread blastosis thrombocytoenia high y cell count and high LDH I think. Okay. So how many major criteria and how many minor criteria should be present to confirm that you have so three major. So you have to have the characteristic um medical site proliferation andia and one of the driver mutation and not meeting the other myoid malignancies and one of the minors. So liquid sources or spinomegali or thrombocytoenia so three major I think and one minor if I'm not wrong. What is the prognostic score for mono? So there's a few prognostic scoring systems. I think the dips plus um there's um I think mix I think. Can't remember the top of my head to be honest but score is high. What would you offer to this patient? How old is the patient? 60. So I think um yeah, if he's Jack positive with um high DP score then I would offer him Jackto inhibitor um solutinate rockolutin. Can you use anything else? If there's evidence of anemia, I think we use molutin. Myofrosis patient would have anemia all the time. Can you use the first line? I'm not sure. I can't remember my head. You can use them first time. There's no issue with that. Yeah, I think patient who don't because if you you prefer to start mobil to give mobility rather than proxaling if they have significant anemia. Can you offer them transplant? Yes, if they are high risk. I think if unless unless they um you know if they I'll start the drug two inhibitor and then I would refer them to transplant center for assessment. If they are transplant eligible we start jet two inhibitor till the match is available or suitable donor is available and then they can be transplanted. Okay. Before they progress. Yeah. And if the transplant is not an option or there is no match available, you can use any of the Jack inhibitor according to the new myop fibrosis guideline 2024. It can be malotinib as a first line. It can be as a first line. Okay. with dose adjustment according to the renal function and plate curve. They have given the table what should be the dose with different ticket count. Okay.
Okay. This is another case the last case of the day. Another anemia case. This is 32 year old female with progressive fatigue, shortness of breath and ja. He is file as well and has a sore throat. Enter. This is power 10. Now we will go to power 50. This is an equal blood. The full blood count hemoglobin is 60, white cell count is 13 and plated count is 400. Report the blood thin and what are the different diagram. Sun. Yes, I'm So this is a young lady with symptomatic anemia upper and lower respect infection. This is a Nikos blood pin. You can see it in your lab. Right. So starting with red cell there is red cell and isobuloscytosis at different sizes and um there's there is spherosittes microside chromatic cells teardrop drop few stomach sites as well. Can see fragments and there is red cell aglutination. uh and platelets looks increased with mild plated anocytosis. We just seen one neutrfil so far looks okay. Normal granulation and lopulation and this is fairly okay as well. But there is a vaculation inside or what's this? Yeah. So reactive. Yeah. This so toxic changes and vaculation. Mhm. Is the patient septic you said or Yes, patient has symptomatic anemia with signs of upper and lower respirator infection. Okay, I don't have the clue from uh for the neutrofil vaculation but so so given the spherosite in the red cells and policy chrommesia I would say there's a feature of hemolysis in the red cell lineage reactive changes in the white cells the neutral in the neutrfils toxic changes. So I need to rule out autoimmune anemia. Okay. So the impression is himolytic anemia in this. Yeah. Hemorrhotic in general. Yes. And what investigation you will request? Uh will do LDH, hypogtoloin, B12 folate ion studies, Billy Rubin. That test and ion studies for completion and given the I need to check infection markers. So CRB and send sputum cultures, blood cultures and respiratory viral swaps. Which infections are associated with autoimmune anemia, myopplasma mainly. So yeah, plasma antigens and biology. You will send the atypical screen in this patient as well. We have sent for those to score and CRP blood pressure. Oh, perfect. Okay. Yeah. What can be the likely cause of hemolysis in this patient? Uh likely would be warm autoimmune hematic anemia. So I will correlate with that test. Secondary to mylasma pneumonia infection just say infection because we don't know what can be the source of infection but this patient has symptoms of upper and lower respiratory tract infection it can be bacterial it can be wor and then they can ask you what are the different causes of autoimmune anemia again you will say primary and secondary secondary causes are infection autoimmune malignancy sp and birth. How would you treat this opinion anemia? Uh so mainly supportive transfusion. Uh I said earlier today uh patient symptomatic and treat the underlying cause if infection. So treat the infection. So if it is cold daglutinine it mainly will be supportive treatment and treat the underlying cause. If it is warm autoimmune heatic anemia with IGG positive in that I will start steroid. So just where can benefit starting steroid in active sepsis or active infection. In this patient if you start steroid you will feel the first. Yeah, just because the question was a bit general. Uh so if I stick to the microplasma code when they give you a scenario in the exam all the question will be related to this related to the scenario but if they want to ask you a general question then they will say um how would you treat autoimmune anemia generally but this specific patient we know that this is most likely secondary to infection there is no role of steroid if the patient is symptomatic with anemia then yes we can give her give the patient transfusion folic acid VTE prophylaxis should be done and treat the underlying cause steroid is for primary when whenever there is a primary of autoimmuneia then you will give steroid otherwise if you give steroid this patient the immune system will be suppressed more and the infection will spread in the body more. If you're giving steroid, we are suppressing the immune system, right? Yeah. And the infection will spread in the body because you have weakened the immune system more by giving spirit. But if it was a primary autoimmune then yes my own body is destroying my red cell then I would suppress my immune system by taking steroids. But whenever there is a cause you treat the cause. No need of steroid no need of any other chemotherapy drug. Okay. Okay. These are common daily life. anemia secondary autoimmune healic anemia or mechanical hemolysis or lucidlastic fare or myof fibrosis or CML etc. These are common cases of anger that we face in our practice and these are the cases that appear in the exam. In exams in the FRC part exam there is not always complex cases. These cases appear we had RN deficiency anemia. We had B12 deficiency anemia. In the same exam we have HBSS straightforward case. We have infectious mucus straightforward case. mental and we are very straightforward cases just like we see in our daily life but it is the exam pressure and first day of the exam and just 9 minutes for each slide so things get messed up. So um if you are working here in UK so you must go to your lab and see all the Nikos line. The lab scientist may have the Nikas folder or drawer in their lab. See them and ask for Nikquas login. They may ask you to make your own by using the their lab u passwords or they may give you the access to the folder where they would have set up the PDF files of all the um niclide nicl slides there's a number like 2207b this is the number of this nicos slide okay so when you write it in the folder the answer will appear with detailed explanation by Abra or someone else. And um still you have a month or month and a half you will paste two more Nikquas um slides before the exam. Try to report them. The quality of the slides in the exam is just like these slides. These are Niko slides. You will see all the cells like this. So once your eyes are um addicted to Nikos slides there will be no difficulty because when we change slides from lab to lab the quality is different and the appearance of the slides and blood cells are different. So from now on start seeing a lot of Nika slides so that you are okay to them and do not change your microscope stick to one microscope. This is the advice I can give you from for the exam from morphology. Thank you very much. If you have any question, you can ask now. No question then enjoy your day. Take care everyone. Bye.