Morphology session 1

Is the screen visible to everyone? Yes. Okay, this case is for you. Okay, this is a 48-year-old man presented to ED with P only. Uh, presented to ED with FA. F. Okay. Yeah, so the blood test shows hemoglobin of 130, white cell count of 31, and platelets of 180. Okay. BMS did a blood thing and it shows some abnormal cells. Okay. So this is the 50 power because the cells are these slides are oil, so I cannot go 20. Okay. Can you move around? Yes. So I will move around anyways. Um, here I can show, uh, here I can see, um, monomorphic, uh, lymphoid cells. And there I have, I have 100 power as well. Whenever you want. No, no, no, no, it's okay. I don't need 100. Um, there is increased these lymphoid mature looking lymphoid cells. These have high N:C ratio, but there are cells which with the immature chromatin and prominent nuclei. I can see the neutrophils. Platelet count is looking normal. Neutrophils. I will take you through the exam style. Okay. First, I'm moving around here and there, and then, okay. Then my question to you would be for a five marks or six marks, report the blood film. Okay. I do not expect a diagnosis in this, uh, thing. I just need a report. I will take you to the blood cells. E.E. We show you in the high power now. You can report the blood film. Yeah, red cells are mostly, uh, normochromic and normocytic, but I can appreciate two populations. Some are like with normal, uh, uh, uh, some are completely filled, but others are normal. I don't know whether these are transfusions or not, but, um, there is increased population of lymphoid cells. Most of them are monomorphic and mature looking, but some of the cells are bit larger and having a prominent nuclei, like these cells. And platelets appear, uh, within, like, uh, platelets are normal and unremarkable. Can you move around? For the, we go back to 50. Yeah, there are neutrophils present. I can also see some arrow sites or see some artifact and smear cells are also present. Smear cells and mature looking lymphoid cells. U, normocytic, normochromic, red cells. There are some, I don't know, spiroides are completely filled, uh, red cells. Dr. Shahim, I think there's some some indentation in some of the, yeah, I can see there is indentation, but, um, when the Amar was on high power, then I can't see the [Music] indentation. I was not like convinced with the follicular sort of the indentation. Is it through and through in follicular? Most of the cells are like small, mature looking lymphoid cells. There is smear cells and, yeah, here this is, there's a cleaving is present in some of the cells, but not all. Again, there's a cleaving of the cell, uh, nuclear cleaving is present in some of the cells. [Music] Okay, so now how would you write in the exam to report the blood cell? Uh, in exam, we should comment on all three cell lines: red cell, platelet, and white cells, or any other abnormal cells or any other abnormal feature. And, uh, I guess, uh, in reporting that these are the main features. So that's what I'm asking you. You are sitting in part two exam. This is for you. There is a five or mark question. Yeah, the question is asking you, please report the blood film. The patient has come to A&E with persistent fatigue, and his white cell count is 31, platelet is 181, and hemoglobin is 130. This is the blood film. Report the blood film. Okay. Um, just one minute. Dr. Amar is waiting in the waiting room. Can you please add her? Amar is not here. You guys can add because I cannot see. Because I can't see. Amar is here. I can see. I think everybody can, um, admit the guest in this. Add. Yeah, I have admitted two people before, so it's, I think everybody is here. Okay. Okay. Coming back to the question. Uh, in reporting, the red cells are normocytic, normochromic. There are few, um, I can appreciate few, um, spherocytes, but otherwise, um, it's normocytic, normochromic. Um, there is increased population of lymphoid cells which are, uh, having a high N:C ratio and, uh, somewhat mature chromatin, but some of the cells have prominent nuclei. And I can appreciate the neutrophils and platelet count is, um, appear normal on the slides. And there are smear cells also noted. You start with the blood film shows lymphocytosis or mature lymphocytosis. Okay. Okay. Okay. Lymphocytosis is the main feature in this blood. Yeah. Then because you are addressing the doctors, theology people now, because this patient is in A&E, you are not addressing GP. Then we can bit describe that the nucleus is mature, some have cleaves, uh, [Music] withs are fine. There are two smear cells and the red cell morphology is okay. Okay. Now, this is half of your report. What is your impression? It is my impression is like it's lymphoproliferative disorder and probably it is, um, chronic lymphocytic leukemia. But I would like to rule out. Ask you, I do not expect a diagnosis from. Okay. I have not given you any, uh, any flow cytometry. Yeah, yeah, yeah, yeah. So you were correct. You're saying that this is a proliferative disorder. So, okay. The blood film is consisting with most likely with lymphoproliferative disorder. Okay. Okay. Now, still your report is not complete. You need to suggest something. So in suggestion, I would like to do, uh, flow cytometry. Minor typing for. So you would, you would recommend that, uh, this patient needs further testing like blood for immunotyping. Find out the lineage. Okay. So now your blood film reporting is complete. Okay. Yeah. So now, uh, in the question, they may have given you, uh, immunophenotype. So you can figure out which type of, uh, lymphoproliferative disease this is. But now the next question can be, what are the differential diagnosis here? Okay. What will be your differential diagnosis? Uh, my differential diagnosis is, uh, for LPD is a CLL, chronic lymphocytic leukemia. It's could be a small cell variant of mantle cell, or it could be follicular as well. I can, I want to rule out follicular as well. So you have given the differential of mature lymph. Yeah, that's correct. Now you have a five marks of blood report, two marks of differential diagnosis. You have three marks remaining. Which, so how will you manage this patient? Yeah. Do I? Huh? I would like to check for like an indication for CLL management if there's an indication for treatment because count is 31, hemoglobin is 13. You don't know that this is CLL. Okay. This patient is in. You have the blood film. You're asking me how would you manage this patient? Consider this is a real patient. You are a registrar on. And you have a lymphocytosis. What would you do? Patient is fatigue. In the for hematological, like C, as hematologically, I would not treat the patient at 30,000 count. I would see whether the patient is, what is the stage of the disease? What are the like other parameters? Is there any lymphadenopathy, bulky hepatosplenomegaly? Because at 30, I would not treat the patient. M. You are not treating the patient. You still to diagnose the patient. Uh, will do LFTs, RFTs, electrolytes. I would check management. If, if they ask about the management, can we start from the history? That clinically I will, uh, go for the few points and then I'll go further. You will take, you will take history from the patient. You will do clinical relevant examination. Exactly. You will send the blood film, flow cytometry. In this, if you have any, uh, B symptoms in this patient, he mentioned only fatigue. Upon a history or examination, if there is any B features in this patient, you may admit the patient and go for imaging. So in, like, in management, we start from the history. We ask for the B symptoms, weight loss, pyrexia, night sweats. This is for three months. Okay. Investigations. In just a number eight, you cannot write big lines in the, uh, morphology section for three marks. So assessment of the patient, and investigations of the patient. Okay. If there is any indication in this patient, like, uh, organomegaly or B symptoms, then we need to admit the patient to decide, treat this patient, or can we start allopurinol? He whose count is 30 only. We will not start. No, no. So if in management, so we can write, we have to ask for the history relevant to the, whatever the, like, if it's a high-grade B symptoms, or if it's a low-grade lymphoma, like if it's a GI something. I, I just, I'm just, uh, in general asking. In management, we have to include point about the history, then we have to point include the point about the staging and the prognostic factors, isn't it? Yes. But in point, because this is for three marks only. Okay. Yes. Now, for example, this is the blood film, and they have given you a flow cytometry which says this is CD5 positive, 19 positive, 10 negative, 20 positive. Yeah, and 200 negative. Then, yeah, do you have a diagnosis now? Then they can ask a diagnosis because they have given you already a phenotype. Okay. CD5 positive and 200 negative and 10 negative. Negative. 19 positive and 20 positive. Yeah. Can you, what is the diagnosis now? I have given the, if it's 200 negative and mantle. Yeah, because 23, you didn't tell 23, and it could be mantle because the 5 positive, 10 negative, and 200 negative. It's could be mantle because CLL will be ruled out. Yeah, yeah. So there are two differentials for CD5 positive: MCL and CLL. Yeah, I mentioned 200 negative. If you have asked me, what about 23? I would have told you that it is, it is negative. Then it's CLL is ruled out. It is mantle. Then what about the cycling and? Yeah, SOX 11 is positive. SOX 11 and Cyclin D1 is positive, then it's mantle. Mantle. So this much will be asked from you in a morphology question. They would not ask about treatment or trial or anything. Just these questions: report the blood film, um, what are the differentials, what are the, uh, what investigations you will do next, what is the initial management? Okay. Or four questions will be asked. More for the report. Make a good report. They do not expect a diagnosis from you in the, in the reporting site because you do not have a phenotype or cytometry. Yeah, unless I told you about the immunophenotype of this case, you cannot make a diagnosis. Yeah, the report contains explanation of the blood film, your impression, and suggestion of next steps. These three components make the blood, blood or aspirate or bone marrow report. They will be for. Okay. Thank you for your input. Who wants to go next? Any volunteers? For Amar, I would pick on you. H. So this is a slide. This is a spot diagnosis. FL. Yes. Report the blood film and for six marks and four marks, what is the management of the patient? So, uh, do we have to explain the slide or we just do the spot diagnosis? You have to report the blood film. Just like any blood film, you report. You just report the blood. Okay. So from here, I can see, um, RBCs are normochromic, normocytic, increased platelet count, and there is, I can see neutrophils and I can see, uh, Trypanosoma cruzi with prominent nucleus and at posterior edge, there is a kinetoplast and a flagellum. It's a and the flagellum. You're describing it as Trypanosoma. So I will make it 100. Yes. So at the anterior end, there is a flagellum, and in the middle, there is a long nucleus, and posterior end has kinetoplast, and it is, um, so this one is. We do not expect this much detail from you. Okay. Yeah. So you have identified Trypanosoma. Yeah. Comment on the red blood cells, white blood cells, and platelets. That's it. And they would not expect whether this is Trypanosoma cruzi or Trypanosoma brucei. Okay. You have seen the Trypanosoma. That's it. That's it. So now you have commented on the blood film. Your impression is consistent with Trypanosoma infection. And suggestion. Now, uh, suggestion for, uh, further testing. Yeah. You have commented on the blood film. You have got the diagnosis. What would you write on the suggestion section of the blood film? Suggestion is, this blood film is suggestive of, uh, Trypanosoma. MH. And, uh, further testing can be done by, uh, Trypanosoma antibodies to confirm the diagnosis. Anti-antibodies can be done. Or, uh, I do, I have to evaluate the patient? Sorry, do I have to do, uh, other investigations like chest X-ray or anything? If the patient has symptoms. You will not write these things in the blood film report. H. But that's it. So we can confirm the diagnosis by serology testing or antibody testing against, uh, Trypanosoma. Confirmation and type of Trypanosoma, uh, species is needed by RCI, like Reference Lab, not Reference Lab. Then, and management section. How would you manage this case? I think it was no, uh, I don't remember allopurinol or benzimidazole. If you at allopurinol, no one will give four marks. So you have to refer the patient to infectious disease. M. Drug of choice is pentamidine after consultation with infectious disease. M. And sending, uh, samples to Reference Lab for confirmation. Okay. Drug of choice is pentamidine. Pentamidine for Trypanosoma. I, it's not allopurinol. Is it enough to write? I will refer it to, uh, for the Reference Lab and to infectious. Yes, because you cannot do anything else for, uh, infectious disease patient. So I would refer to infectious disease. Have to be treated by the infectious disease people. So refer to infectious disease, lab, sending samples to the Reference Lab. And, uh, for more marks or a good impression, you can write drug of choice is pentamidine for Trypanosomiasis. Okay. Or nifurtimox or benznidazole. All right. Make a habit of, uh, blood film, aspirate, or bone marrow. Define the reporting. You may be, you may be knowing the diagnosis. The diagnosis carries only two marks. If you do not write a good blood report, you will lose a lot of marks. You may fail the question even if you know the diagnosis. So in the exam, the half of the marks is for reporting the blood film or aspirate or bone marrow. Who's next? Who's volunteer? Son. Hello. Yeah, can you hear me? Yeah, I can hear you. So this is a 50-year-old patient presented to ED with shortness of breath. Upon chest X-ray, there is a pleural effusion in this patient. The full blood count shows hemoglobin of 101, white cell count of 73, platelet count 150. This is the blood film. So, uh, so I will start from the from the RBC. So there is the, uh, hypochromic, normocytic RBCs. From RBC because the main feature is lympho, lympho cell count. Okay. The blood film shows blah blah blah. Okay. So, uh, so there is marked lymphocytosis. The lymphocyte, these lymphocytes seem to be mature and, uh, with the dense chromatin. And, uh, there are few cells with the, uh, few, uh, smudge cells, uh, can be seen. And, uh, so there's a mature, uh, count, um, count is raised on the film. And, uh, few lymphocytes with the blabs, cytoplasmic blabs. And, uh, the platelet count seems normal, a bit decreased. So, so what is your impression? So it's, um, um, mature lymphocytosis with [Music] the with the blabs, cytoplasmic blabs. So it's, um, with a circumferential [Music] H. Okay. Is it a marginal one? Maybe I'm not, I'm not sure about it. This is a mature lymphocytosis and the, there are cytoplasmic blabs. Yeah. There is pleural effusion as well, and white cell count is very high. Proliferative disease. What would you suggest on the blood film? What to do next? So I will, um, ask for the immunophenotype of that patient. I will, um, suggest the investigation for the immunophenotyping and the flow for that patient. Okay. Next question can be, what is the expected immunophenotype in this case? Could be CD [Music] M. Do you have any diagnosis in your mind? It, it looks like to me the, um, marginal zone. Marginal zone could be in DD. I'm, I'm not sure about it because there, there could be some circumferential cytoplasmic blabs are there. Uh, um, I would not go for hairy cell as the count doesn't favor for that. So, so CD maybe CD 27, 103, 31, 23. They could like help to go towards the diagnosis. So expected immunophenotype in this, um, case is CD2 positive, 5 positive, 7 positive, as well, and 52 positive. Let's say the scenario says the flow cytometry shows 2 positive, 5 positive, 7 positive, and 52 [Music] positive. Then it could be the, uh, T, T-cell, maybe not. Okay. So you have reported the blood film and you have asked the question. What is the expected likely diagnosis in this case? Two marks. The next question would be, what cytogenetics are involved in this case? Two marks. Genetic? No, I, I sorry, I don't exactly remember the cytogenetics in, in exact in this case. Okay. So 14, 14 translocation is the cytogenetics here. This question was also for two marks. The last two marks are, what are the first-line treatment options in this case? I think it's CD52 if positive, then alemtuzumab can be given in that. Um, okay. All right. Yeah. So this is a T-cell prolymphocytic leukemia, TPL. MH. The blood leukemia. You mentioned that the nucleus is mature, cytoplasm is empty, blabby. Patient has pleural effusion. TPL patients usually come with organomegaly or cytosis with high white cell count and T-cell markers are there. Okay. So the question would be to report the blood film. TPL was a question in the Autumn 2023. So going for Autumn 2024, this can be an expected question. Excuse me, anybody can see NOA or Sundu because I cannot see them and I cannot admit them. Okay, messaging. I cannot see them in like, yeah, I cannot see them. Both CNU and, uh, Dr. Amir, I have a question. If I have got such kind of morphology and there's no cytogenetics, no immunophenotype, so is it, is it easy to pick either it's a T-cell or it's a B-cell TPL or it's like lymphoma? TPL has a typical B cytoplasm. You, you mentioned, uh, hairy cell. They don't have that type of B cytoplasm. And those cells are a plasmoid type of cells. These are not plasma cells. B-cell lymphoma, you said it's a plasmacytoid cell. The Dr. marginal, I was saying, yeah, yeah, marginal zone. In that. Yeah, sorry, I was confused with the marginal zone in that because, um, I, I was couldn't recognize on morphology either it's a marginal zone. No, marginal zone would not have this type of lymphocytes. They have hairy type of lymphocytes and not big blabs like this. These cells have, they have all hairy-like projections. M. And the, the white cell count is not that high in marginal zone. Okay. Okay. That is the big point as well. Okay. So for reporting TPL, like in writing, because from, you should have a writing practice. Cytogenetics expected, the immunophenotype, and treatment because it's very straightforward treatment for asymptomatic, symptomatic. Then, uh, empath. Thank you, Dr. Amir, for the nice case. I have, uh, Dr. If, um, if they ask for the morphology, and in the morphology section, we, we divide in three portions, like description, impression, and suggestion. If impression, you couldn't tell about the, like, in impression, mostly you could be towards the diagnosis. If, if that impression is wrong, so all the morphology will be like, uh, there will be no marks for the morphology. If, if there is impression is wrong for that. No, it is just an impression. You will do further testing, okay, to make a diagnosis. Sometimes we think this is a CLL case, but once the immunophenotype comes back, it's MCL or something else. That's why you just suggest, you say most likely or likely or probable impression is okay. You do not say completed, this is the blood film of CLL or MCL or follicular. You do not say like that. Example. Okay. So Masuma G. So this is, um, GP referred blood film of a 35-year-old boy, man, 35, 35 M. The full blood count says hemoglobin is 140, white cell count is 11, and platelet count is 250. Anybody can admit Roman because she's asking to admit. I cannot see her. He has been admitted now. Okay. M. GG, the BMS referred the blood film to you. M. Because he has found some abnormality in the blood film. So I will take you through the blood. Take a minute or two and then report the blood. Okay. Right. E. E. Yes. Now you can tell us your comments about the blood film. So this is a blood film of a 35-year-old male which shows mainly neutrophilic leukocytosis and some toxic granulation in the neutrophils, and with unremarkable RBC morphology and platelet count. Other than neutrophil and toxicity, I couldn't, I couldn't appreciate anything. Uh, these are neutrophils. So I thought they might be. I couldn't, maybe this is a toxic. These are all neutrophils. There are no parasites. No. The blood shows. Is there any stacking of RBCs on on that? I'm on one. I'm on the edge side of the blood film. That's why. Okay. Okay. This one is eosinophil. But the other ones which you showed before were neutrophils. Dr. Mar, maybe initially I thought it was eosinophil, but, uh, there, but this one is neutrophil. No, uh, I have seen a patient who had a similar type of eosinophils with all stages, and they were looking like neutrophils. So I think these are eosinophils with all stages, dysplastic here. You have found the myelocyte of the eosinophil. I don't see there is any myelocyte. These are on all I can see dysplastic. This is eosinophil. You. Okay. Uh, no, CNU is right. When you see like hypereosinophilic syndrome or any clonal sort of eosinophilia, you do see like, um, different stages of eosinophils. I have seen AML as well. The patient was hypereosinophilic with the organ involvement and all stages of eosinophils are present. Yes, but in this film, I, I, but this case, yeah, not in this case. This one is eosinophil. The other one is neutrophil. Eosinophils, you can recognize very easily. No, Dr. Amar, these are these are larger than neutrophils. Look at the size and somewhat pinkish and granular. The granules are also not neutrophilic granules. Yeah. However, nucleus is dysplastic. So there is might, might not granules are more in favor of eosinophil with more pinkish rather than neutrophil. Neutral. [Music] Okay. We need to complete the report. Report the main abnormality in this blood film is is eosinophilia with abnormal granulation and nuclear lobulation with no parasites. Normal looking with normal, uh, platelet count and unremarkable RBC findings. What, what is this beside the neutrophil? Lymphocyte. So this is half of your blood film report. I need a complete blood report. You need a complete blood. Okay. Yes. This is a GP blood film. M. You have to say something to the GP. What to do next? So we can tell that this is eosinophilia and secondary causes of the. We can ask him to find out the cause whether there is any recent travel history, any drug history, and any history of allergy. Where there any signs, symptoms related to organ involvement? Like the, you have to, in report further investigation. Report, you have to suggest. Usually you suggest, uh, secondary causes. I will write, rule out the reactive and the clonal causes of eosinophilia. No, but you have to write IG for allergic or asthma or any allergic reactions, and then autoimmune. You can address. You can address stool for actually there is a long list of reactive causes. The important ones: stool for ova and eggs, IgE level for allergic, then any reactive, autoimmune. So in your report, you cannot write all of these things. You just have to write only one sentence. Please exclude reactive causes of eosinophilia. The GP knows what are the reactive causes of eosinophilia. So I have to write, rule out the reactive causes of eosinophilia. And clonal causes. If you write clonal causes, I will give you zero marks. How the GP can rule out clonal causes? You are the hematologist, or GP is the hematologist? Okay. GP. So for GP, you will write the reactive causes only. Yeah. So what is the definition of clonal? [Music] Us more than one persistent eosinophilia, more than absolute eosinophil count more than 1.5, and it is persistent. I think more than six months. One, one month. New definition, but that is hypereosinophilic. Yeah. So you have to suggest as well to repeat the full blood count with blood film after a month. If there is persistent failure, then you are thinking about a clonal cause. In this, one more time, he would have excluded the reactive causes. Then is the role of hematology. Do we do we advise them to re-examine the patient or no? We just said, rule out the reactive causes and repeat the CBC after one month. Yes. We just say, rule out reactive causes, repeat the full blood count with a blood film after a month. If there is persistent eosinophilia, then you have to do your us. Sorry, if there's persistent eosinophilia, then then you have to do a panel for clonal eosinophilia. Uh, Dr. Amar, is there any cutoff of eosinophil count where we have to refer the patient to emergency as well? That is the hypereosinophilic syndrome when the patient has shortness of breath or, uh, chest discomfort, and a full blood count shows very high eosinophil count, and there is no other cause for high eosinophilia, then this is hypereosinophilic syndrome, and this is an emergency. You have to give the patient steroids as soon as possible. I think this, uh, emergency treatment depends on the, uh, features, clinical features, or symptoms of the patient along with if you find eosinophil count high. Yes, on microscope. Are, are these eosinophils different in color? They're all orange. Just orange. Okay. So if no reactive cause is found, you have to send the blood for clonal cause. What, what test would you do? This is a three-mark question. PDGFRB on FISH on peripheral blood. PDGFRB or FGFR1. Even serum tryptase level. Two marks. And third, you do the target. You also ask for the molecular targets like JAK2 and BC-ABL, BCR-ABL. You can send a blood peripheral blood for FISH. You can send [Music] um, you can do bone marrow biopsy in the patient. And the third thing is, if there is associated myeloproliferation, you can send blood for C11. So this will be the complete eosinophilia question. We had a question in this exam. Given how you come, they ask, must report the blood film. What question would you ask in a history regarding eosinophilia? And what next step would you require? You would, you would do if there is no reactive cause for. So which test advised out of this all the three we mentioned because it was a three-mark question. And in history, you ask about the travel history, drug history, and allergy history. Yes. Medication history, travel history, allergic history, any systemic disease history, because eosinophilia can be a part of gastrointestinal syndrome, neurological syndrome, autoimmune diseases, or part of chest diseases or chest infection. Thank you. Then that would complete, uh, your answer. Now, a lot of the questions in our exam were like this. They were not expecting diagnosis from us. They were just asking us regarding the, uh, approach. How we approach. So if a GP blood film is there, GP do not understand the hematology language. Make things simple for him and always advise them what to do next and give them a suggestion. [Music] Let's suppose, Dr. If, if this was a case of neutrophilia, so what would be your approach? If it was GP and he has sent you this film with neutrophilia, then again, reactive causes for the neutrophilia. Is he any background diagnosis? If he is using any G-CSF injections? If he has any infection or not? Because leukemoid reactions or neutrophilia can be because of infections, drugs. And if these things are out, then obviously malignancy. If he asks you, what next investigation would you advise? So in advice, you will say that I will rule out the first, rule out the reactive causes. If no, and the infection markers of the patient, plus a blood film. A blood film, you are seeing already. If infection markers are not there, they are normal, and patient does not have any medication history, then you are suspecting that this may be a myeloproliferative disease, maybe a CML or neutrophilic [Music] leukemia. If it is only mature neutrophils. Okay. So how many we have done? [Music] This is the last one. And who is Amar? I've done. [Music] Then Roman. It's me. Dr. Sindhu. You have a 60-year-old man with anemia and yes, with anemia and fatigue. Uh, anemia and fatigue. Anemia and fatigue. Okay. Okay. Got it. Beautiful. It's beautiful. Beautiful. Because I have done last two days before. That was my patient, if I'm not wrong. Yes. Okay. Start reporting the blood film. Okay. Uh, this is the blood film of 60 years old, uh, who presented with anemia and fatigue. A peripheral smear shows, uh, rouleaux formation, I mean, secondary to the anemia. And these are normocytic, normochromic, and, uh, platelet counts, uh, are normal. I can see the platelet counts in the background. And, uh, there is a lymphoid cells, and these are intermediate size, and, uh, uh, these having the, uh, bluish, bluish abundant cytoplasm with circumferential hair projections. To me, they look like plasma cells. I'm also confused. Is it the plasma cells? To me, it is a plasma cell with rouleaux formation. Yeah. To me, it is also plasmacytoid. Or one or two look like plasma cells, but there is a basic cytoplasm. But why is there a flow cytoplasm? Like there is see a perinuclear halo and perinuclear? Yes, perinuclear halo is prominent. Yeah. So it's plasma cells to me. It's initially one cell is looked like, like, yeah, in this case, was confused, but there is a perinuclear halo and the cytoplasm is not that much as like as of for hairy cell. But but Dr. Shen, morphology is very deceiving. I know, I know. So it's not very much important on the, on the higher resolution. The cells become more clear because on the low resolution, that looks like the hairy, but when barely look at them, there is the perinuclear halo that you can see on the high resolution here. But cytoplasm is wavy, as in this case. Synu was right, but there is a perinuclear halo is prominent in all cells. Yeah. Yes, there is a halo around the nucleus. If these plasma cells are present in peripheral blood, so I think it can be leukemia. Plasma. I asked you to report findings. Okay. So these are plasmacytoid cells. These are intermediate to large, large in size, uh, with eccentric nucleus and scanty amount of the, uh, basic cytoplasm with perinuclear halo surrounding the nucleus. And nuclear chromatin is somewhat condensed. Is there anything else which I have to add? So two marks out of five marks. Again, report the blood film features in the blood film. Your impression. What to do next? Now, I, uh, comment on the RBC, uh, and platelet and WBC that these are okay. So the most likely, the blood film is consistent with most likely, yes, consistent with, uh, plasma cell dyscrasia or plasma cell disorder. Okay. Plasma dyscrasia. Now, this patient needs, what, what is your suggestion to do? What to do next? He has anemia, he has fatigue, he has plasma cells in the blood film. What to do next? Uh, then I have to, uh, check what is the cause of anemia and what is the hemoglobin. Bone marrow, flow cytometry, FISH. Then your imaging. First, you write the serum protein electrophoresis, immunofixation. And, uh, you commented on the cells. You're thinking most likely this is plasma cell dyscrasia. You write urgent investigations are needed like flow cytometry and bone marrow biopsy for this patient for confirmation of diagnosis. This completes your blood film. So in blood, in reporting, you are saying we have to advise our further investigation as well. Yes, but not a big story. Just the investigations which would make the diagnosis. So this patient has a lot of plasma cells in the peripheral blood. You have mentioned that blood film shows, uh, multiple plasma cells with rouleaux formation and, uh, normal platelet count. Most likely the film is consistent with plasma dyscrasia. To confirm the diagnosis, we need urgent flow cytometry on the, uh, blood and the bone marrow biopsy on this patient. Similarly, Dr. If we are suspecting leukemia or some LPD, either we can say, you can correlate with the immunophenotyping and the cytogenetic report, or we have to advise. Cancer. You for you advise flow cytometry, cytogenetics for confirmation of diagnosis. Which line would be better? This is, this is AML patient. You cannot send a patient home. You have to admit him. So you have to admit the patient. Even in LPDs as well. No, if they are asymptomatic, then you do not need to admit. They can be followed in a clinic as well. Then, yes, but you don't know. Just a film came to you as referred by your BMS. So how would you know that the patient is symptomatic or not until and unless you go and see the patient and assess him for? So what we do normally that if there is a leukocytosis or normal blood film, if the patient is at home, we call them. How are you feeling? How are you today, sir? This is a practical thing. But what will you do in an exam scenario? So in exam, if this is the blood film, then you would suggest this patient needs urgent, uh, investigations to confirm the diagnosis like blood for flow and bone marrow biopsy. Okay. Thank you. It means, okay, what we see on the blood film and we have to advise further for the confirmation of diagnosis, right? Yes. This would complete your blood film report. Okay. Normally, we do like this that we advise based on the suspicious. Yeah. You cannot leave a blood film without suggestion. You would see a TTP case today. You just report it and I leave it. No, you urgently contact the patient or find out where is the patient to see him yourself and assess him because it is a hematological [Music] emergency. Sorry, Dr. If, like, it's, it's a slide of TTP, so, uh, what will you advise in your reporting? Yes, urgent referral. Yeah. So this is most likely suggestive of, uh, likely TTP. It is a hematological emergency. This patient needs to be assessed urgently by the hematology registrar or consultant as soon as possible. You can. And same thing for TTP. TTP as well. You cannot write these things and then keep the slide aside. No, you have to mention that I will inform them too. Inform my team about this case so that he can be assessed. But we are supposed to be holistic. So why we write urgent referral to hematology? No, you are just writing a report. Your colleagues may be on the board or your colleagues. You are present in the, in the lab. You are reporting the, uh, blood. Yeah, I think Dr. Amir is referring towards the more towards the emergency. If, if you are not in emergency and you have to refer towards the emergency, then to you, you need to refer towards some emergency registrar or hematology. So if I have a, I'm on morphology rotation and I'm seeing the blood film, I cannot leave the morphology to go to that patient. I will call my colleague who is holding the UN C bleed and inform him that we have a patient whose blood shows, uh, and I'm suspecting a TTP in this patient. Can you urgently assess that patient? Then that registrar will leave everything and will go to the TTP patient. Okay. Or AML. Did you get my point or no? Yeah. For.