Transcription
Please allow your friends to enter the meeting cuz I cannot see the main screen. This is the case. The screen is visible, right? Yes, we can see that. Yeah. Okay. Right. So this is 60 year old lady with pension. This is power 10. This was power 10 view for this patient. And let's go to power 15 now. This patient is severely tens as you can see. Yeah. List the sides there. No platelets. Hello Mor is our senior biomedical scientist consultant. Morning everyone. Morning. Nice over there. Peilla sites. I have shown you multiple power 50 possible TTP. Is the calculation screen done? Cogulation screen is normal. All right. Okay. Prominent nuclear there. All right. Would you like to refer this to clinical hematologist or no? Oh yeah, definitely. Yeah, this would be referred to definitely a suspicious blast there as well. Okay, but the TTP well sorry a lot of shites there but no nuclear RBC's. No, I I definitely refer this to the consultant. Okay, good point. So, we need a volunteer to comment on this blood pin to report this blood pin from the clinical hematologist cuz the lab have referred this pin to you. I can go for this. Yes. So, report the blood. So I'll start there is um um red cellopytosis with multiple irregular contracted cells and um um electroytes. Um also there is um clear thrombocytoenia. We um there is a population of monuclear cell with high NC ratio um nucleus open chromatin a granular cytoplasm and visible nucleololis um pilobed spobed nucleus if you can see it a granular cytoplasm. So I need um so this population of cytoplasm or of um um blast cells are very suspicious. and desend for low side 23. Yeah. Okay. It's not clear if it is only indented or by lo I need to look at for other this is indention because indent okay uh this side of the nucleus don't have a separate nuclear right so yes everyone will send this blood for flowy symmetry but what is your impression what you will to proceeding this blood close you sent it yesterday and it it is now weekend Monday is bank holiday. Mhm. And um the result will come on Monday most likely if if someone has elaborated this to the HMDS. What do you think is going on here in this paper? M um cogulation is coagulation profile is normal but I think um yeah so it is I will call the patient to assess see her clinically if she's stable and um patient is in the hospital because she's unwell unwell. She has pancipenia. She feeling very tired like me and she has bruising. She has recurrent infections. So you have found out that you have commented on the component of the blood pin. What is your impression? Yes. Everyone even if I give this patient this blood thin to hematology SHO he will send he will say that I will send his flowymetry because he has noticed some abnormality in the blood but I want you to make a report as a clinical hematologist because you will be sitting in the part two exam recent uh in the future. Yeah. What do you think is going on in this patient? that you want to confirm on why you want to send me to HMBBS throughout leukemia. Um your impression so your impression is uh likely acute leukemia because you you cannot confirm things on peripheral blood. So you will say most likely uh acute leukemia. Yeah. Send blood to HMDS for urgent and this patient boneopsy as well. Yes. Confirm the diagnosis. Mhm. So the blood f shows transipenia. Yes. But but you will still not get full marks because you have not commented on the full features of this blood. As the as your colleague mentioned that there are many. Yeah. In the red cell lineage there is hypocchromia in the red cell lineage as well. So you need to commend on all the finding. Sure. Yeah. Because if I am your examiner in the part exam, I will have a list of u findings in the blood. So I will see whether Ravia has mentioned hypocchromia or not. Yes. One more. No minus one. Ravia has mentioned in this one or toyopenia in this one. Yes. One mark. low minus one. Why people fail in part two exam? Because they know the diagnosis. This is acute leukemia but they don't know how to write it. How to write the report in the exam. Okay. When you appear in part exam and people come out in the center. Oh say slide number one was acute AML. Slide number two was mental cell and slide number three was TPL. But when the result came they failed the exam because yes they know what is the diagnosis they don't know how to report the blood. So FRCAD exam is not a knowledge exam. It is a knowledge plus skill exam. Okay. Okay. So you need to know the skill of the exam as well. Pass the exam whatever however you like in the real life if you want to say this is acute leukemia that's it. No one will notice it. But for the exam purpose you need to pass the exam. You have to write it like the like they want on the exam. Okay. Okay. Many brilliant people fail in the exam because they don't know the skills. Many average people pass the exam in first attempt because they know the skills of it and better to write the report with your pen on a paper so that you have a practice because I know you're going for exam. Mhm. And there are a lot of morphology quiz slides on in our channel. Go through the slide in 3 minute and write your report in part. You will have a good practice. Okay. So this this was acute myoid benmia on close and transmia always keep as your def sorry am I ask please uh you mentioned that uh if you missed a finding you will be uh you will be uh having minor one. It's not zero. You will have minus. I mean if thromocytoenia has one mark. Mhm. You will not you will not receive that mark. Okay. Yeah. Because you have not mentioned homocyopenia. So if the report mark is six marks, you have written the diagnosis everything but you have not mentioned homocyopenia. You will not receive six marks. You will receive five marks. Five marks. Yeah. I thought that it's minus. So you will receive four marks. No, no, there there is no negative marking but you will not get a mark for that thing. Yeah. Okay. He is right. Whatever he saying. Yes.
This is the second case. This patient has um worsening petty and he is 60 years old. The GP has sent this patient to you to the hematology outpatient clinic because his anemia is worsening and his um symptoms tiredness is worsening as well. The spot blood count shows white hemoglobin of 102, white cell count of four, dictate count of 155. This blood fil goes to a biomedical scientist first. This is power 10 over here. And now let's go to 50. These swites out. few kind of sites there as well. So what do you think as a biomed scientist I should say consultant? Sorry. Yeah. Um it's a possibility is there like liver kidney problem here as well. Is LFT un been done? Yes, LFTs are normal. UA is normal. I am on the side for a reason. There seems to be projections on the Olympic to the top there. Yeah, I don't like that cell there. It's getting some two projections on it. What is your impression? Sorry, doctor. The patient was presented with what? Progressive anemia and fatigue. Yeah. Well, it's not a classic HCL, but I'd have to have a look. One more sound. The film does look a little bit on the older side. Is it like artifacts? Yes, it is ed artifact. Yeah, the liver and kidney function is okay. Would you like to refer this toy? Um little bit unhappy about some of the lymph maybe lot of kindites. Yeah, not happy with that cell there. Yeah, I I'd let the consultant have a look. Okay. So what is your impression and then refer to possible within projection it's not could be like SVL or I'm sorry business or it could be HL I definitely refer it um possibly send for flow sir is there any stenome in this This is 13 cm. Yes, sir. Yeah, that's a bit of concern. This is the picture at 100 bit blurry. I think this cell has more hair than me. Right. So the film has been referred to hematology clinical hematology. And who is going to report it? I can go for this one. Yes, please report the blood film. You are sitting in FRC Path exam. Okay. So um the blood film is showing um monomorphic population of um lymphocytes um with cytoplasmic projections and um nucleus um shows um dense chromatin um homogeneous dense chromatin um with slight um indentation. Um the film also showing um anemia with uh mild microytosis and uh some ruler formation. Um we are we are on the thick side that's why there is ruler for Mhm. go on. Yeah. All right. And plateless piece adequate. Um yeah I would like so this is um I think I will I will say picture is suggestive of LPD. I will send the sample for immunotyping to to clarify exclude what? So this um to exclude or confirm her cell leukemia um or splenic marginal zone. Okay. Anyone disagree with this report? Looks like everyone agree with you. Okay. So, whenever a patient has progressive uh anemia and there is spleenal which may be present or may not be present. You should think about her cell leukemia but you cannot say this is definite hairy cell leukemia as you mentioned correctly lymphop proliferative disorder is a correct term because you will confirm the things um close to me and and the um bone biopsy in this patient maybe it's not very clear but this one look like whole jol And this one as well, but it's not very clear. Okay. I missed out. So, yes, correct. This is LPD and the close autometry was positive for a cell leukemia. So, whenever there is anemia or panicipia, always look the thick side as well. because our junior missed this case because they were only looking at the thin side of the film. We uh we when we were in ST3, we were told as well that do not go to the thick side. Always focus on the thin side as well. No, look the thick side as well. the hairy cells are always hidden among the among the cells on the thick side of the blood. Okay. So yes, this is hairy cell leukemia. You can see hairs all around the cells and in modular zone spenic modular zone the hairy cells will be at the end. Some here on this end and some hair on this end which are called polarized hair. polarized hair project. Okay. Right. What flow simemetry panel do you expect in this patient? So I will run the LPD panel. Um I will expect to see CD CD25 11 C positive CD 120 103 and 123 positive. Um yeah um and if it's a variant um hairy cell or or I would expect to see 25 negative there is no variant her cell now it has been removed after WH 2022 and the variant her cells they are a bit bigger with a prominent nuli and more cytoplasm and they have luccoytosis. Their white cell count is high. I see. Okay. And if you want to give this patient treatment because his his clean is making him discom giving him discomfort or anemia is worsening. What are first line treatment in here leukemia? So the first line will be purine analogs cladropin. Um yeah I think uh it's cladroin. Um weekly for for five weeks. Yeah dripping. Yes. Perfect.
The third case is a bit difficult but those who has sharp eyes may pick it. It's because the findings are a bit Not clearly visible. month. This patient is 19 years old and his fever is not responding to antibiotics. He received 2 days of IV antibiotics but he did not respond to it and then he become confused. The blood cultures were negative. Viral to sold was negative. CT scan was negative. Feritin was not high. What was the HP? Sorry. The HP was 120. Val count is low as you can see little 55 go to a bit abnormal. there as occasion like bite seldp or something like that. expect to see more. He is a white guy. So J6 PD we did that but it was he was not any history of trouble. Yeah. No. Yes. He went to India. Okay. We got to times 100. Are there some rms? Yeah, I saw I saw something because it is not a typical presentation. I mean the findings in the blood it was missed initially but then someone picked it in the lab. Is it feliparum malaria because there is there are some inclusions in the red cells maybe but they are very very small one. Yeah, they are small. Yes, they call for on the circumference of the red cell. Yes, the like the we have seen fibarums but the rings are not that small like we say it cover 1/4 of the red cell this is I think one10th of the red cell they are so small and they are so small that you cannot you cannot distinguish clearly. No, I mean it's more clear here. It was before like a single dots. Yeah. Yeah, there is a double chromatin in one of them. Yeah. And they are like bulging from the red cell as well. Yeah. The one in the center is a bit appearing as a ring form. Yeah, there's no there's no dots. I can't see. Sorry. There was no gite even in the no the the same the size of the cells are the same. This is quite for fulum. They're not enlarged. Yeah, nice round. And some has two as well. Oh yeah. Yeah, you can get multiple infos for them. Yes positive. The reference say this is interesting to see where they position though because they're not usually like that. there many people missed it. Even in our land many people missed it because of the Yes. But this patient has thromocytoenia and he was not responding to not responding to the antibiotics. Right. Then we could repeat the blood fil and see why is that and when we did the oddity it was positive. H yeah it's not a clear one they are small within the cell though you know bigger and yes sometime unusual presentation we can get for these bottom makes the cell size bigger I think right or no not usually the same size it doesn't it is The I think it's the Yex. Yex make the side the rest size bigger. Yeah, they make him a mean boy. They call the ugly ugly parasites and they're probably one of the easiest to diagnose. Yeah, this was the case of persum and it was a bit unusual and it was a delayed diagnosis as well in our hospital but the person survived. He is okay now. His paracetmia was quite high 29%. Yeah. But the tropical medicine did not say for red cells exchange. They say they have some new drugs now and they say give that medication to the patient patient will recover and he is okay but was previously now what was the medication that they gave? I don't know about but it was not the artison which is usually given in the peripherum previously we used to do the red cell exchange with this amount of parasitmia and with cerebral malaria cerebral malaria is an indication of red cell exchange but they didn't do exchange they give him drug and the next day patient was okay I will check that drug what was the name of the drug that I give the patient. Okay. Thank you. It is not the usual it is something else. Was he having renal impairment as well? No, he had only fever and significant thromocytoenia and then on the third day he developed confusion. Okay. We did CT scan for him. and the CT scan was normal. It's good that you ask about the travel history and you go for power 100 as well. If you read the malaria guideline in BSH 2022, it says that if a patient has unexplained thrombocytoenia, you should consider malaria in your defensial diagnosis as well. But obviously a travel history is important. If he has traveled or someone in in his family has traveled recently abroad, he may have brought mosquito in the back.
This is the fourth case. This is a 55 year old lady with progressive fatigue. Again, hemoglobin is 110, white cell count is 20 and plated count is 155. This is over. Lucasytosis is probably neutrfilia. Let's go to 50 now. There's a few basils around which is a bit concerning. Mhm. You haven't seen Dr. How are the LFTs? LFTs were normal. What's the effort count? Count was three. Okay. percentage I know absolute that I would not remember it's only symmet We're tempted to say it's possible CML. You think that they say possibly CML? Yeah, I send it for I definitely refer to the consultant. Too many P of there for my liking. Dr. Ramir, does the patient has pleng? Yes. Who was that? Who asked the question? Uh Romano, you need to report this blood film then. Okay. So um the blood film shows luccoytosis predominantly uh neuteria with some left shift and then there are prominent basopils as well. Uh the red cells show uh some of them show targeting. I could see some u sites as well but targeting is prominent. And the platelets are uh I think uh yeah they are adequate. This cell the one that I'm looking at now is a bit suspicious maybe having prominent nuclei but I'm not sure about that. It might be a blast. uh so with the background of spleno megali as well I think uh I'll send u this is most likely milo proliferative neoplasm and uh I'll show I'll uh send the BCRL for this patient also does the patient have any other infection. How was how was the CRP? And no infection. Okay. So I I'll send u I think for BC or ABL BC or ABL. Yeah. Okay. Why you want to search for BCL? the cross to confirm if it is CMM. Oh, all right. So, this patient has a lot of basophilia, einophilia, cube loss, neutrfils and the u bend form as well with spin magic. This is most likely CML. you would send the blood for DCL which came back as positive. Okay. So what are the prognostic factors in CM? Uh sorry Dr. Amir it's not on the top of my head at the moment. Anyone else? What are the prognostic factors in CML? Um, spleen size cm block and I think blast percentage in bulu can't remember very well. Sorry. the level of BCR ABL after 3 months and after 6 months or something else. What else? H count. Okay. What else? Dr. Can we uh we can get the prognostic score from the ELTS also. You toss the score that LTS is a score that we use in UK for the CML. So always divide the prognostic scores into two disease related and patient related. This patient has high ALTS score. It is a bad protocis. Or you can say individually this patient has low plated C, high blood count size is high, low HP. These are two prognostic. If major root abnormalities are present, this is a poor prognostic factor. resistant to firstline treatment is a food prognostic. If the patient is having multiple coorbidities, the patient performance status or coorbidity index is high. This is a poor prognosis. If the patient refuses treatment, this is a poor prognosis. Okay. So, prognostic factors are always disease related and treatment related. What are the major root of the CML additional Philadelphia? From 8. Mhm. It's 3Q deletion monosome 7 isocchromosome 17 triome 8 21 additional Philadelphia chromosome 19 no 21 and what are the first line drugs in CML? That's it. You ask what are the first line drugs in CNL? I put the siblot can be used as first line as well. Oh, the certain and when when will you use the sertin as a first line? If we need to achieve quicker response then we can use the satin as a first line. For example, for young females, if she she want to get pregnant or young and having high risk disease and we need to go for stem cell transplant then in that case we can use the sativas first line. Yes, high LTS high-risisk disease to achieve remission quickly. These are the few indications of second TKI does something second generation TK. All right.
This is the last case. This is 20 year old female with cervical lymphopathy. The full blood count was hemoglobin of 110, a white cell count of 14 and plated count of 200. This is power 10. Right mo I think you are the only biomedical scientist who leave with me. So you have to commend. I will go to 50. There's a few there's a bit of unnecess I get it. F shift there. Yeah, they're quite large mon nuclear cells. Mhm. Not atypical mon size. What is your impression? It's probably possibly an infection with monocytosis and um it's like a promyocytes probably. Yeah, it's probably my probably an infection some form. Is the correlation screen okay? Yes, correlation screen is okay. CRP CRP was 14 slightly elevated. There's a little bit of polychrome. Maybe it could be the stain helmet cell there. I'm sorry. What was the pit count? Count was normal 200. Right. Would you like to refer this to hematologist? Um, if I in a normal situation with a number of neutrals, they don't look abnormal. This patient has another right. Okay. Yeah. Yeah. Smear cell there. How old again? Sorry. 20 year old right see what this is I'm inclined to go for infection but um Yeah, I can't see anything really. There's monocytosis neutrfilia pls. Okay. Sometimes they'd be up in infection or low. Um possibly slight poly chrommesia there. Patient's not really that anemic, is he? I can't see toxic granulation. Mhm. There was a prominer site there. So did a left shift but I can't see any mile sites about too sure if I would refer this. I'm not sure. I'd have to see a bigger field to be honest. Mhm. Yeah. I have to have a good look around at the sides as well just to see if there's any cells accumulating at the periphery as well. Okay, let's refer it to hematology. Is it um continuous uh high this count? Is this count continuous? Has been high for a long time or is it just the recent recent there was no previous count to compare with it's not a chronic in reality probably I would just say it's a neutrfilia monocytosis possible infection. Mhm. Just repeat to monitor. Let's take opinion from clinical hematologist. Let's see what this is. Yeah, Dr. Can I go ahead? Yeah, go ahead. So uh the blood film shows u luccoytosis with prominent neutrfils a bit of left shift and then the monocytes also show signs of activation with vaculation. There are some lymphocytes with I could see some lymphocytes with abundant cytoplasm and scalloping around the red cells. And the red cells also show um an isopulytosis with some aliptoytes, a bit of hypocchromia, some teardrops, occasional fragmentation. Platelets look adequate. So uh I think on the basis of this morphology is most likely some infection. Uh I would like to check for EBV infectious monuclesis markers as well. If the patient has lympadinopathy patient has a throat. Okay. Patient has a sore throat and painful cervical lymphodenopathy and you have seen a lot of activated monocytes reactive lymphocytes. So this is not leukemia. This is not my monolocyic. This is just a simple infection monucleiosis in the patient. Okay. If it was milonocitic, you would have seen a lot of loss monoplasts as well. And this patient is anemic. As you can see, there is a clearcut hypocchromia. Yes, leukemia can happen at at any age but if the patient has sore throat or painful cervical lymphopathy young age then usually it is infection related reactive lymphocyto. One thing which I would like to mention here is that scalloping is not a feature of a reactive lymphocy. We have seen many cases um in the previous sessions where there was 19 year old with monoblastic leukemia, 60 year old with monopolastic AML. They had a lot of monolast in the blood film and all of them were scalloping. So do not tell your juniors that if a lymphocy is scalloping this is reactive you may miss a diagnosis of leukemia. So scalloping is not always a feature of reactive bases. It can be present in leukemas as well. I think we should come out of this scalloping related reactive lymphocytosis thing that if there is scalloping of the red cells this is rectite. No your colleague may miss a diagnosis of acute leukemia and there will be a delay in the treatment of the Okay. If a patient is having significant anemia, red loss, u promocyenia, blood film is fil of monoblast and shows scalping. I would say this is reactive. White cell count is 130. I would say this is reactive. It's not. So do not misguide yourself and by by scaling related thing. I have seen a lot of cases recently where they were having AMLS and they were having scalloping as well. This was the last case and can you please share this thing with your medical colleagues? Okay, let's bleep hematology in a hope that the bleeds to the hematology team will reduce. Okay. Do you have any question you can ask? Yes, please. Uh can I ask regarding the case of AML with shift sides does it carry a significance of associated? No. No. Or if the patient has infection or sepsis or DIC then the patient will have tysto. If the patient has folic acid deficiency or betal deficiency, a patient will have pystoides. Pystocides is not always a feature of PTP. If you see if you see a folic acid deficiency patient, the patient will have a lot of hestoides. It does not mean that this is PPP. Yes. Okay. Okay. Thank you. Thank you Dr. Air. Nothing then we'll stop here and enjoy. Thank you.