Transcription
So this is an open session. Uh, please admit everyone who is in the gallery because I will not be able to see the screen of team. All right. This is the first case. This is a 70-year-old lady who has a background history of progressive multiple sclerosis and she presented to us with intracranial hemorrhage and she has pansy opinion. This is power 10.
>> [snorts] >> Now I will go to Power. For those who have joined again, uh, the scenario is that this is a 70-year-old lady with a background history of multiple sclerosis presented to us with intracardial hemorrhage. Blood, full blood count shows pensipenia and this is the blood film because of the pension cells are quite few in it. But those which are available. Evelyn, are you there?
>> Sorry, did you call my name?
>> Yes.
>> Oh, okay. Sorry. Yes, I'm here. Dr. Amir.
>> So you're going for the exam. So, you need to report this blood. Do you have any thoughts about this blood film?
>> So this blood film, the striking feature would be the presence of these very large, um, atypical mononuclear cells. Um, so they have, uh, they display an irregular nucleus. Um, some of it shows bilobed and and some are appears folded. The chromatin is open, some with prominent nucleus. Uh, they have an abundance of, um, this esuropilic granules, sometimes obscuring the nucleus. Um, I'm unable to appreciate any cells with our rod so far. So the red cells otherwise.
>> The red cells otherwise are unremarkable with just mild, um, anopiculoytosis. Platelets are, um, reduced. Taken together, these findings would be highly suspicious of an acute promositic leukemia and I would suggest referral to, um, hematology. There is also NRBC as well.
>> Yes. Do not say refer to hematology. This is a hematological emergency. You should say this is acute. The impression is APML, which would need confirmation on PML aurora stain.
>> Okay.
>> This is an emergency. I need to see this patient by myself and will inform my consultant to start the treatment as soon as possible in this patient.
>> Okay. Not that. Thank you.
>> So I think I have shared you the hematological emergencies fine with you guys. Um, when there is an emergency, say it. This is a hematological emergency or medical emergency which needs urgent hematology input. Refer to hematology means they will refer it after six hours, after seven hours when they become free. So on an emergency situation, you need to say it, vomit it to the examiner and act urgently on it. Similarly, if Dr. Your voice is muted. So similarly, if this is a warden storm patient, for example, and his, uh, and his, um, paraproin are 100 and he is confused with extensive bruising, you cannot say refer to hematology. You have to say that this is a hematological emergency. I need to see the patient of myself and inform my consultant. [clears throat] Talk to apheresis's, uh, unit to arrange plasma exchange, change urgent. If it, if it was a CLL, mental cell, or follicular lymphoma, then I can say refer to hematology. But in TTP, in hyper viscosity conditions, you have to act quickly. I think in this film, there were only two bop cells and few hyper granular cells. Okay. So it is easy to pick that this is APML, but your response will make a difference in the exam to pass you in the short question or fail you in a short question. I think there are no other blog cells to show you. Um, this is the another one. I will make it at 100 power.
>> [snorts] >> Let me find out that document. Document. We'll share that document again today. The hematological emergent is you got what treatment will you provide to this patient?
>> The immediate treatment I would provide will be all transverinoidic acid for this patient and send off. Um.
>> If the next part of the question is, discuss the immediate management of this patient, how would you answer?
>> Um, admit the patient to hematology. Look for any signs and symptoms of bleeding. Send off the coagulation screen looking for DIC, um, and also peripheral blood for fish for translocation 1517 and also reverse transcriptase PCR and then start, um, uh, without even waiting for the results of this, um, genetic test. And if the patient has features of DIC, to support, um, accordingly to keep the iron r less than 1.5, platelets more than 30, and fibrinogen more than 100 mgs per deciliter. Okay. So who is the another candidate of fa dish? You are the candidate for the exam as well. Uh, you have heard the answer. Please correct the answer.
>> [clears throat] >> Sorry, my, uh, so I think in the first instance, um, um, I would, um, as I say, u, you mentioned that see the patient, uh, discuss with the consultant, uh, and in the management option, I'll explain the diagnosis to the patient. Uh, I will, uh, do send all the baseline investigations, uh, including, um, um, coagulation, LFTs, virology. And then, um, um, obviously urgent fish, um, and for PML ra and PML staining as well. Um, then, um, um, as Emily mentioned, supportive treatment, uh, depends on patient's bloods. Uh, so it will include, uh, uh, fibrinogen replacement, platelet, uh, transfusions, um, and, uh, uh, most importantly, uh, the definite treatment at this stage will be etra, um, so, um, I think, uh, um, that's probably the initial management, and then further management will depend on, uh, confirmation of diagnosis, risk stratification, and patient baseline status, and we also need to do further investigations like echo, ECGs, and things like that.
>> Okay. Echo and ECG will come later.
>> Yes.
>> Um, but this patient has APML and she has intracranial hemorrhage.
>> Oh, I didn't, maybe didn't heard about the intracranial.
>> Hemorrhage. Sorry. Yeah, I missed that too. So I think obviously for, um, I don't know if it was diagnosed on a CT scan, she will need an urgent discussion with the neurosurgeons. Um, um, we need to keep the platelet target nearly over 100, with the platelet transfusion. Um, again, we need to nearly normalize the coagulation studies. Um, um, and u, um, so further will depend on the neurosurgeons whether they want to manage it conservatively or it will be too high risk, obviously, for a patient to go for the surgery, but it will be the neurosurgeon's call.
>> Okay. Right. So please, uh, read your question twice in the short case because, um, you have only nine minutes and you have no, uh, no choice for any mistake. Okay. Intracranial hemorrhage, u, discuss the targets. Platelets about 100, hemoglobin about 70, FF, uh, the, sorry, the fibrinogen about two, as per our trust protocol. Some hospitals say about 1.5, right? As per my trust protocol, um, and discussion, discuss with the patient if she has mental capacity. If no, because she has intracranial hemorrhage, if no, then the next. And then yes, the, uh, APML related treatment urgently. At you can include, uh, set, you can include the arsenic, or you can include the adorabine. It doesn't matter now, whichever you want, but that would need a regular electrolyte check. Does cyto reduction have a role to play? If the white cell count is very high, then you can give cyto reduction. If, if the white cell count is less than 30, we usually do not give any red. It depends on hospital protocols as well. Uh, right. This is the second patient. This is a 54-year-old patient who presented to the emergency department because of the gum bleeding. This is power 10. Now I will go to power 50. Make it more clear. Our hemoglobin is 106, white cell count is 25, and platelet count is 130. Thank you. Right. Is there any volunteer for this one? S. [clears throat] You there?
>> Yeah, I can. Yeah, I'm here.
>> Yeah. So you can see there is a, um, large to medium blast with, uh, with open, uh, sorry, open chromatin that is prominent nuclei, and you can see also the cytoplasm, and the NC ratio is reduced, and there is also some cytoplasmic. I'm not sure about that. And there, the red cell, uh, shows there is, um, uh, mild anisopulytosis, like upper, and thrombocytoenia. I can see also the neutrophil had reduced as well.
>> Mhm.
>> So my, my probable diagnosis for this case would be acute leukemia with the presentation of, uh, of, um, of bleeding, nasal bleeding.
>> Okay. So tell me your report. You are in the exam and they have asked you to report this blood film.
>> Okay. So the, the main thing that I have to comment on there is the blast, which is large to, uh, uh, medium to large, uh, with some of them with reduced, uh, NC ratio, and also I see, uh, that, uh, some of them have nucleus, some of them, but not all of them, and there is nuclei with open chromatin, and, uh, uh, comment on the red cell. Uh, I can see that there is red cell, uh, anu, uh, cytosis. Um, uh, there is no, uh, >> uh, I didn't see any, uh, startupia. Uh, there is all, uh, neutral, there is neutropenia as well.
>> So you have to comment on everything you see in the blood, even if it is red cell, uh, or anisocytosis. You have to mention these things in all cell lines, even if it is a whole jolly body in the red cell. As the prominent feature here are the blast, you have to, uh, you have to mention them first.
>> Okay.
>> Yes.
>> You, which you have commented on, then you have to mention there is a block of polyro. Yeah. Yeah.
>> And the blood film findings, and, sorry, the platelet findings, then the impression, and then your suggestion as well.
>> Yeah. So, yeah.
>> Your impression is acute leukemia.
>> I need to send for Yes. And I'm sending for immunophenotyping, for immunophenotypic blood, and for cytogenetic and molecular analysis.
>> Yes. So always say impression is acute leukemia, and you will confirm the lineage on close.
>> Yes.
>> Because we don't know, sometimes they appear as biphenotypic or mixed lineage. Yes. It is very clear that this one has granules, but you never know. We have seen many cases in practice where we think this is AML and it turns out one or AML.
>> Yes. Yeah. Yeah.
>> So comment on the cell line first, which is affected here. You have seen a lot of blast. So comment on the blast first. Then you can comment on red cell lineage, that there is anisocytosis, or there are a few fragments as well. Then you can comment on the platelets. The, there is thrombocytopenia. No platelet plugs seen. And then your impression. This is leukemia. You need to confirm this. This need to be confirmed under by by flow cytometry. This patient would need investigation in the form of bone marrow biopsy and admission to hematology.
>> Okay. Thank you. And then if they ask you, uh, for in the next part of the, uh, short question, what is the immediate management of this patient?
>> Immediate management, of course, would be like, uh, admission of the patient. He comes with the bleeding. He needs, like, to be, uh, examined and, uh, check his, um, uh, uh, full blood count, clotting, and fibrinogen, and there is a bleeding, he needs a transfusion. Uh, the, uh, I, when I need to know the number of the of the blast by itself. So if the blast number is very high, so we need to do a cytoreduction for this patient and put in our mind also, um, the hydration, um, and when the confirmation of the diagnosis, we will need to, uh, uh, recognize the patient and accordingly, we can start immediately, uh, the chemotherapy, and if he's a candidate for transplant later.
>> He's a candidate for transplant if it depends on on the patient. I, I didn't consider the age of the patient. I don't know the performance status, a lot of things which is need to.
>> Patient age is 54, but do not talk about transplant in the immediate management.
>> Is therapy? Yes.
>> Yes.
>> Immediate management. I saw that old management. So it made.
>> In immediate management, uh, discuss about clinical, uh, clinical assessment of the patient. If the WBC count is high, you can give cytoreduction. If the patient is bleeding, you can set a target for the patient. If this patient has gum bleeding, you can refer, uh, send a referral to max team or dental team to assess the patient. Okay. And then your bone marrow biopsies, the rest of the organ function test, and consultation with the patient that we have seen your blood film. It shows likely this, this all these things come under acute management.
>> Do not mention about transplant if they ask you about immediate management, okay? They will give you a next question that this patient has a normal karyotype on cytogenetics. What is the treatment? What are the treatment choices for this patient? The last two mark question in the short case is this patient has a normal normal karyotype on cytogenetics after bone marrow biopsy. What is your treatment choice for this patient?
>> I'm asking you.
>> I will have to start for him. um chemotherapy in form of DA, and because he had no any site to, uh, risk cytogenetics. So I expected that he may get a remission with two induction, uh, chemotherapy.
>> What, what is the treatment choice? I think in a, in a choice, we have to mention Vena as well, because we don't know the fitness of the patient, u, and then, uh, as someone mentioned about DA, if it's normal karyotype, then, yeah.
>> Yes, for fit patient for normal karyotype, you have DA.
>> DA standard, yeah, standard chemotherapy. But you have all, you always have to say that I have to see at the patient's comorbidities, performance, and fitness. If she is not for, not fit for DA, then I will consider less intensive chemotherapies, which are now many.
>> Okay. When is we have, um, there are many others as.
>> So the next patient is a 19-year-old patient who has presented to the hospital after a fit. Okay. And now he is confused as well. He's just 19 years old, and the CT scan shows, uh, hemorrhage, intracranial hemorrhage. This is his blood film. And go to the thin spot. So his hemoglobin is 90. His white cell count is 600, and his platelet count is 80. He had a fit. Then now he's confused. And CT scan shows hemorrhage. And this is the blood. I will go to power 50. I think we will stick on this, uh, slide because all the slides are like this. Anyone any volunteer to comment on the blood film report the blood?
>> Can I have a go?
>> Yes. Yes, please.
>> Yeah. So, um, there is a, um, leukocytosis, um, with, um, pretty much monomorphic red cell population with high NC ratio, u, visible nucleoli. Um.
>> Okay. You have commented on the white cell lineage. What about the other lines?
>> Um, there's anemia with red cell anisocytosis. No red cell fragments seen. Um, thrombocytopenia as well. No clumps. Um, also going back to the white cells, some of the nucleus, they look a bit thting a notch, and, um.
>> Mhm.
>> I see. Um, it might be some of the cells have some granulations, but not all of them into the cytoplasm. Um, okay. And just a few normal, uh, lymphocytes.
>> Normal what?
>> Um, lymphocytes like, um, with the, just a few. There's one in the middle. Okay. Right. So what is your impression?
>> Um, so it's a leukemia with leukocytosis. Um, patient needs, um, so I need to send an urgent flow for lineage confirmation. Um, and cytogenetics. Patient needs urgent admission and hematology, ITU, or cytoreduction, to phoresis.
>> Okay.
>> For the transfusions, red cells.
>> Mhm.
>> BL to keep the the platelets above 100.
>> Cuz you got the bleed.
>> So this is the report. In report, you comment on the cell lineage, your impression, and your suggestion what to do next.
>> You have commented on the cell line. You have mentioned your impression that this is acute leukemia, and your suggestion is to urgent blood flow or the flow at the hematology team assessment and patient admission under the, uh, ICU because the patient has intracranial permanent. Yeah.
>> All right. So now you have sent the flow for this patient, and the flow has turned back as CD19 positive, CD10 positive, CD20 positive, and TDT positive. So the lineage markers 19, which indicates a B, um, B cells lymphoma. Um, TDT is a marker for the ALL, either BL or TL.
>> Mhm. I think that's the case from the today's essays.
>> I think that's the the case from the days essays from the from yesterday. Sorry.
>> I don't know. Um, and looking back to the blood film, I think there are some type of plasmic blebbing, which is seen in a lamp.
>> Mhm. Globin glebins can be present in many. So flow cytometry is indicating BL leukemia.
>> Okay. So this is, uh, BL because TDT is positive, and you have B cell markers as well. Now, the next question is, acute management of this patient. So as, as, as we mentioned, patient needs to be admitted in IU because in bleed, he needs urgent cytoreduction in chemotherapy. Um, and also close monitoring for TLS. Um, the initial management for all BLLL is the preface steroids, but given this high, uh, vessel count, there's an increased risk of TLS, so yeah.
>> And it's good hydration, respir case. Right.
>> So you have suggested suggested this treatment, and then.
>> Um, no, I, I think because I think probably he needs a local, localis first to reduce the to remove, um, the, uh, malignant cells. Dr. Reika said that she would like to answer this question as well. So let's see her answer what she said. Sir.
>> Yeah. Um, this patient.
>> Okay. Um, uh, for the acute management, the patient needs to be immediately, uh, admission in ICU with all ABCD assessment, and, uh, patient needs, uh, to be, uh, look for the signs of other, uh, leocytosis, and for patient will go for leukapheresis because of high TAST count. However, the platelets will be maintained, and because of bleed, it should be more than 20, I think for the leukapheresis, and, uh, soon started with the DEXA. If ALL is confirmed, then for DEXA with TLS, uh, protection, and, uh, uh, patient needs to be counselled and explained about all the results and complications, and, yeah, MDT, MT is first neurosurgeon involved will be the first. Or Naveen says that she would like to answer this question. Naveen, can you hear us? Naveen. Naveen Vera.
>> Hello.
>> Yes.
>> Yes. Uh, regarding the immediate management, I'll divide it into multiple aspects. One will be, uh, management of the bleeding and this thing. So I'll be keeping the platelets above one. I'll be assessing for the blood count and first is the patient assessment. Then, uh, second will be man, uh, management of the immediate symptoms. The patient is having bleeding. The patient will be admitted to the ITU and we'll be have taking a neurosurgeon opinion and keeping the platelets. It's about, uh, one lakh in, uh, in view of, uh, intracranial bleed. And third will be management of, uh, the, uh, primary management of the patient. The patient is having hyperleukocytosis, and we look for symptoms of hyperviscosity, and, and also the patient is at high risk of tumor lysis syndrome. So we will be starting on tumor lysis prophylaxis with hydration and allopurinol, allopurinol, and the definitive treatment would be, in this case, to be starting on preface, preface steroids, or for cytoreduction, we can go for, uh, leukapheresis if facilities are present, and, uh, concurrently, we'll be counseling the patient regarding the new diagnosis and we'll break the bad news and we'll also provide them with the treatment of options, and concurrently, we'll also send, we'll also be sending the sample for further, uh, risk stratification of the disease and to determine the main therapy or definitive therapy. Okay.
>> So there are multiple aspects in this, uh, patient. The patient has very high white cell count. He has bleed. He had a fit. He is now confused. CT scan shows intracranial hemorrhage. The priority is to reduce his white cell count after admitting him to the ICU. Okay. So you will check the coagulation screen, make sure the fibrinogen is above 1.5. If it is less than 1.5, you have to give fibrinogen to the patient because if you do leukapheresis with low fibrinogen, the bleed will, the bleed will expand. Make sure you mention coagulation screen with cross fibrinogen. This is important. You replace the fibrinogen first, and then you go for leukapheresis. This patient will need platelet transfusion as well because platelet count was 80. And then you, you do the leukapheresis. You start the cytoreduction with chemotherapy, uh, in the form of dexamethasone or in the form of chemotherapy, cytarabine. You want to give. We usually avoid chemotherapies because this patient will go for any trial in the future, uh, to avoid that problem in the future. So cytoreduction for the intra, for the high white cell count is first, after transfusing him within consultant, if it is low, and platelet transfusion, then neurosurgery, surgery, um, consultation for possible intervention. He had a fit, you have to give, uh, you have to consult neurology as well for, uh, review and their opinion regarding epidemics to prevent further anti-epileptics in, in this patient. Discussion with the patient, but he is confused, so you have to inform the next of kin. And the next important thing is the TLS management in this thing. Do not forget leukapheresis. Do not forget TLS. Do not forget ICU admission, um, and the neurology and neurosurgery involved. These were the few important things in a good management. Uh, if you miss any of them, then the answer will be considered as unsafe. So do check fibrinogen. Why we don't do, um, leukapheresis in APML? Because APML patients come with DIC, and then fibrinogen is very, very low. So if you try to do leukapheresis in APML patients with intracranial hemorrhages due to leukocytosis, they, their bleed expands. That's why checking fibrinogen is important in bleeding. I can ask in, in this case, um, you're waiting for flow to confirm the lineage. I mean, do you have time? If it's an APML, you usually think of.
>> No, no, this is not, this is not an APML case.
>> I have told you the flow already that this patient has.
>> B cell markers with TDT positivity.
>> TDT is positive, meaning disease.
>> Yeah, but I was, I was asking in general when initial on your initial investigation, you don't have the flow yet, and you're in doubts about the cell lineage, or if it's an APML or not. Um.
>> Morphologically, this, uh, these cells were not like APML.
>> Okay.
>> Uh, these were all lymphoblasts.
>> They were quite different from the cells of the pro cells of the APML that we saw in the case number two.
>> Oh, I was, I was not here when was case number two. Sorry.
>> Okay. So when we, we, when we did the case number two, the cells were very clear. They were few. They were myeloid looking. They, they were having a lot of granules, and we saw two, two cells which were clearly blob.
>> Okay. This is again a 19-year-old year old old girl who has presented to the emergency department because of fever, and this is her blood film, power 10. Hemoglobin is normal. Platelet count is normal. White cell count is 14, and this is the blood film, power 10. And the biomedical scientist has flagged it up as leukemia. Now the blood film is with you, and let's see what is on power 10 or power 50. Sorry, what was the history? 10 year old.
>> 19-year-old girl. Okay. With, um, hemoglobin of 140, platelet count of 356, white cell count of 14. She has come to the emergency department because of recurrent fever. High grade fever.
>> Recurrent, recurrent, what? Sorry.
>> Fever, temperature.
>> Okay. Yeah.
>> Okay. And she has a background of splenectomy due to road traffic accident. [snorts] >> This is her power 50, uh, film. I have shown you the power. The biomedical scientist has flagged it up as leukemia. Okay. Is there any volunteer? Can I?
>> Yes.
>> Can I have? Yeah.
>> So I think, I think initially when you read into the film, I think I saw some spherocytes. So, yeah. So the, that's a lineage. Um. Oh, okay. There is microcytosis with some red cells with, um, polychromatophilia, in keeping with splenectomy. Some red, some bite cells again due to splenectomy. So when we, when we were telling you the, uh, full blood count, the full blood count, hemoglobin is normal.
>> Platelets is normal. White cell count is 14. So the problem is with the white cell lineage. To comment on the white cell lineage first, then go to red cell, and then platelet.
>> Okay. So affected lineage should be, um, commented on first. Yeah. In the report.
>> Okay.
>> Um, so the, the nucleus from the white cell count looks, the chromatin is condensed. Um, there are some, um, gone.
>> Yeah. So on this film, um, I think it's, it's a neutral film. I don't.
>> There is a smear cell. Um.
>> Okay. So the blood film shows leukocytosis. Yeah.
>> Yeah. Um, white cells are lymphocytes with.
>> Um, scalloping of the cytoplasm.
>> With red cell scalloping. Um, but the nucleus is chromatin is is not open. Um, um, with condensed chromatin, um, looking more like reactive lymphocytes, lymphocytosis. Um.
>> Okay. And I saw some, some normal segmented neutrophils with granulations, the cytoplasm, and the rest of the lineage. Um, hollow bodies, um, cells in keeping with no spleen. Um.
>> Um, so it, it looks like a reactive picture with atypical lymphocytes, probably a viral infection. Uh, I will request for a, um, EBV virology, monospot test. Um.
>> Um, but yeah, again, that the spherocytes on on the blood film, and I think I saw a nucleated red cell initially, which is in keeping with hemolysis, but the hemoglobin was normal. But.
>> I didn't notice the NRBC.
>> Um, it was initially, I think it was someone on the left, but it was just when moving the film, so I'm not sure if it was a blur or right.
>> Just the beginning, but yeah. What investigation would you like to do for this patient?
>> Um, so I would like to, um, to do a hemolysis screen to run a flow cytometry. Sorry, not, not a flow, to run a viral serology. Um, checking for EBV.
>> The viral serology will include EBV monospot, as also CMV and HIV as well. We do all this virology in a young patient. Aftering and then the treatment. Um, so the treatment if, if EBV is confirmed, um, would be, um, monitoring of the LFTs, um, and avoid contact sports, advice the patient that.
>> Why to avoid contact sports?
>> Um, I think EBV can, um, yeah, she's got splenectomy. [clears throat]
>> Do not forget to comment on these cells in your blood film. Okay. This will carry a mark as well.
>> Yeah. So that is a, um, that the band.
>> These are bands. Yes.
>> Anyone disagree with her report? Oh, I think it's a fairly reactive film. There are mature neutrophils with some band forms. Uh, the red cells, as she mentioned, there are some hollow jaw bodies. I can't see any NRBCs as well. I may be able to see one stem somewhere. Uh, there is a platelet anisocytosis with some large platelets, again, keeping in with the, uh, post-splenectomy changes. The white cells, as mostly mature. Uh, there are some secondary granules in cytoplasm, but I'm not sure whether it's just a reflection from the camera or there are actually, but, uh, mostly it's a reactive film. Yeah, it's consistent with the viral infection, likely.
>> Right. So your junior who is ST3 now came to you, what is a reactive lymphocyte? How to differentiate it from clonal lymphocyte? What advice will you give to him?
>> I think if it's a clonal population, usually the chromatin is more open. It's not condensed. Um, and usually the clonal cells are more, the NC ratio is is very high in the lymph, in the lymphoblast with almost invisible cytoplasm. Um, and here in reactive, you can see clearly the cytoplasm, scalloping the cell. Um, and also visible nuclei sometimes in the nucleus in the clonal cells.
>> And also you looking, looking around if it's a possible, you should see abnormalities in the other cell lineages like neutropenia, thrombocytopenia.
>> Yes. In this case, the other ones are normal. Blood is normal. Yes. Abnormalities in other cell lineages. And in lymphoma, you, you see same sizes of the lymphocytes.
>> Yeah.
>> Okay. But in reactive lymphocytes, all the cells are of different shapes. They are distorted. Some are large, some are small. Um, and they have no unified shape. And, uh, the cytoplasm is more bluish, more basophilic. Still, you will be able to see nuclei in them, but it does not mean that they are, they are blast. So they are of different sizes. Okay. There is no unified, uh, uh, shape in it. Some are very large, some are very, uh, small, distorted, u, basophilic cytoplasm. Majority of them has basophilic cytoplasm. There are few cells whose cytoplasm is less basophilic. Other have more basophilic cytoplasm, and, um, the other lineages, they are normal. And for the exam, your patient will be young.
>> The patient will be teenage or patient will be in 20.
>> Yeah. Kissing disease. So sorry.
>> Yeah. Or the, um, fever patient will come with fever or sore throat or cervical lymphadenopathy to distract you, to lean you towards lymphoma. They will say patient has cervical lymphadenopathy. It doesn't mean, um, lymphoma. We all get cervical lymphadenopathy when we have infection. Mononucleosis. Do not write kissing disease in the exam. Write infectious mononucleosis. So we have the last case now. This is a 60-year-old patient who has a new diagnosis of pancreatic cancer. He is febrile with high CRP. She has developed anemia. The hemoglobin is 80 or 0 10. So hemoglobin is 80, platelet count is 350, and white cell count is 14. This is power. I will go to for [snorts] 15. So what, what's the platelet count?
>> 356.
>> Okay. Thank you. All right. So, what do you think is going on here? Is that that one? That's our mean NRBC? No, there is no NRBC here.
>> No, before it was, um, abnormal field or.
>> This?
>> No, not this one.
>> You mean this one? No, I thought it was a dysplastic neutrophil, but I don't know. But.
>> There are some red cell fragments.
>> So report it. Oh. Um, um, Oh, yeah. This one in the middle. Beautiful. How would you report the blood? There is anemia, um, with red cell anisocytosis and red cell fragments present. Um, on the 20 power fields, I would say there are, you know, four or five is normal. Um, the neutrophils, some of them are normal segmented. I think some of them, they're just plastic. Um, couldn't see any lymphocytes. [snorts] Uh, there are some teardrop poikilocytes. A few one now visible in the middle.
>> Mhm. Normal beautiful with the round nuclear nucleus. Sorry. What? Go on with your, with your report. Sorry.
>> Your report. So you commented on red cells. What about the white cell platelets? Your likely impression and your suggestion to the team.
>> [clears throat]
>> Danish, how would you report it?
>> So I would say there is a red cell anisocytosis with presence of, uh, fragments, uh, in high power field. Uh, there are NRBCs, um, and, uh, occasional teardrop cells. Uh, the neutrophil, some are more reactive, hypogranulated, um, and, uh, there are a few, uh, left shifted as well. The platelet counts appear normal, uh, with platelet anisocytosis, with some large platelets. Um, uh, keeping in a history, overall, the film suggestive of, uh, uh, uh, TMA secondary to, uh, pancreatic, uh, uh, malignancy with preserved, um, I would say platelet count. Uh, advice would be, uh, to continue observation, um, check for, uh, treatment of the underlying cause is the most, uh, important management. This patient has a very high CRP as well, as mentioned in the question.
>> Yes. So there are some toxic looking neutrophils and some left shifted as well.
>> Yes. So what would be the treatment of this patient?
>> So the treatment would be from hematology perspective, um, uh, well, it will be, um, treatment of underlying cause, infections, uh, with antibiotics, and, um, there is anemia, so they can look, uh, I, well, in exam setting, I think I would suggest to do hematitics, um, and, um, observation. Uh, yeah.
>> Whenever there is hemolysis, you always say please give this patient folic acid.
>> Okay.
>> Yeah.
>> Yeah. Whenever there is, yes, this is.
>> This is secondary to infection and pancreatic malignancy with preserved platelet count. Related count is on higher side because of the ongoing infection. Um, but if the hemolysis is there, yes, you have suggested hematinics, but you have to suggest folic acid as well.
>> Yeah. Yeah, that's right. So usually such blood films are quite common in our practice, but, uh, in exam, they can give you the BMS has noted multiple fragments, and she's worried for TTP in this patient.
>> So I always look at the scenario again. What is the platelet count, and is there any underlying cause present or not? For example, this is the case that the 50-year-old patient with pancreatic malignancy presented to the emergency department because of fatigue, or hemoglobin is 80, and platelet count is 70, for example, cell count is 13. Would your management be different in this case, or still the same?
>> I think it will be same.
>> There is anemia. There is no thrombocytopenia. It's a lot of.
>> So we can do the DAT and haptoglobin and LDH, just to ensure it's not autoimmune. Uh.
>> Uh, going on a line of TTP will be a bit tricky. Of TTP in this situation. So I need to send urgently for ADAM 13, and I need to, um, I think to confirm the diagnosis with TTP center, and, um, if it is confirmed, immediately I need to start, um, management of TTP. It's just to explain to the patient and prepare, uh, central line, and need to transfer the patient to TTP center within 4 hours, and at the same time, all the basic investigation and prognostication should be done, troponins, and, uh, [clears throat] uh, and also discuss with with the lab for defrost, the plasma. So it will be, he will be start extreme transfusion as soon as possible when he will be there in the TTP center, and if there is a delay in transport, I need to start plasma infusion in my center.
>> Okay. Good. But Islam Abdullah is not agreeing with you.
>> I am driving past comment that, um, can you hear me well? Yes.
>> Right. Okay. Uh, wasn't, uh, there at the beginning, but I understand this patient's got a, uh, pancreatic malignancy or some evidence of fragments, and he's got evidence of sepsis as well. So I'll be keen to, um, review systematically his full blood counts, liver function, tests, and coagulation, especially fibrinogen level. So basically, I'll be making sure that this patient is not in DIC, because patients with malignancies, they usually present with DIC from cytopenia, and it's very unlikely for a patient with a malignancy to have a TTP. It's not the top of the differential diagnosis, but, um, I would leave it at the bottom of my differential diagnosis, but not the, uh, first. The patient needs to be supported by products and treat underlying cause, which is, I believe this is could be peripheral consumption coagulopathy and DIC. Make sure that the patient is not bleeding, and, um, anyway, we need to optimize PT, PTT, and fibrinogen level, platelet count to 13. If the patient has got evidence of bleeding, we need to keep a higher blood counts based on the type of bleeding of the patient. As I said, I was in, um, I did listen to the history very well, but I don't know where the patient is bleeding. So the platelet count would depend on bleeding sites, if any, and, uh, to treat the underlying infection and monitor the patient also, because there is some evidence of some mention and nucleated blood cells. If this is the case, we look at, I think it will be also good to consider hemolytic uremic syndrome if there is any low or deranged renal function test. That's all I think about this case.
>> So TTP is either primary or secondary. Primary is immune TTP. Okay. And congenital as well in the very young age. If you have a secondary cause present, which is the pancreatic cancer in this case, you do not do plasma exchange. Okay. You would, you would discuss this with the TTP consultant, but when he or she knows about pancreatic cancer, they would say not for plasma exchange, please treat conservatively, which means with blood transfusion support, check hemolytic screen, hematinic screen in this patient, and give folic acid prophylaxis to the patient. Do we do plasma exchange in secondary TTP cases?
>> Of course no. If, of course no. My, my question, my answer is just if it is confirmed, but in this case, I understand that he had a cancer. So it is mostly TMA, and even ADAM 13 level will be not low in his case as well. So I agree that will be the treatment should be like support of the patient. Um, clotting profile and everything, but I mean that in case, I mean that if this is confirmed, so, yeah.
>> Pancreatic, pancreatic cancer is one of the commonest causes of.
>> Yes, is a commonest cause and also the worst prognosis as well, worst prognosis cancer as well. So even the, the prognosis be six months maximum for expensive life.
>> And those who are working in transplant centers where they do allogeneic stem cell transplant, they would have seen a lot of secondary TTP as well. Post-transplant, we do not, we do not exchange in.
>> State underlying cause. Yeah.
>> So, yes, if you say that it will be discussed with TTP, is that the case for the secondary TTP?
>> Yes, in secondary TTP, you do not do plasma exchange. The advice is.
>> There is not that much thrombocytopenia in that case.
>> We don't call it TTP.
>> Yeah, because you're talking about TMA and MAHA.
>> No, no, calling that TTP.
>> We are not discussing this case. We have changed our scenario that, for example, this is the case with anemia, thrombocytopenia, and a lot of fragments like this, and he, and the patient has background pancreatic cancer. What would we do?
>> Okay. Okay. Thank you. Yeah. Because I was, I was thinking that in this case, the thrombocytopenia is not that much marked for the TTP. So no, not in this case. We have changed our scenario to discuss.
>> Okay. Thank you. Any question?
>> Yeah. Hello.
>> Yes. Go on.
>> Yeah. I just want to confirm if you're sure that this is a secondary TTP, and we know the underlying cause, do we still need to discuss with the, uh, TTP consultants?
>> If you are sure, then we do not discuss. Okay. But there, [clears throat] is not such mention in the guideline that they should not be discussed with the TTP consultant. We flag them to them that we have a case who who has low, low hemoglobin, low platelet count, but there is underlying suspected cause as well, which is pancreatic cancer. Should we do a plasma exchange or should we refer it to TTP center or not? They would say no, because it is not clearly mentioned in the guidelines, and you are a junior as well. Uh, you always take an opinion of a senior. You will, in exam, you will say, I know this is a secondary TTP. It does not need a plasma exchange, but I will run it through, uh, through the, uh, through the TTP consultant to make sure I'm not missing anything. So this is your safe answer for the exam.
>> Okay. Thank you.