I had a look at the digital morphology NEQAS a month ago. We were told that "an elderly man with no previous history of haematological disease has been admitted to hospital. He is anaemic with a raised white cell count. " Which is far more forthcoming that most NEQAS morphology excercises are, but was still frankly rather sparse compared with real0llife cases.
I had a look and saw:
I felt that this was possibly a case of sepsis (or Jordan's anomaly) in someone with a haemolytic condition. And I said that “without more information any further speculation is frankly guesswork”.
The final report said “It is certainly possible that the polychromasia and nucleated cells reflect a bone marrow response to red cell destruction. However, the abnormal erythrocyte forms present are not typical of red cell fragmentation, membrane disorder, or abnormal haemoglobin. We should therefore consider that bone marrow infiltration (particularly a myelodysplastic syndrome) may be present causing the expulsion of immature and maturing”…
“This is a patient with chronic myelomonocytic leukaemia who had experienced a deterioration in his health following an infection. The features have been described in the narrative, but the diagnosis is not simple. Without full knowledge of the number of monocytes, and a review after the infection is resolved, it is not possible to be fully confident that this is chronic myelomonocytic leukaemia. However, the extensive dysplastic features present should allow a diagnosis of probably underlying myelodysplasia; and a possible diagnosis of CMML could be suggested”.
I spotted the salient features which could equally well be applied to what I thought it was as well as what it supposedly was.
I had a look and saw:
Wbc (in order of priority)
Vacuolated neuts
Dohle body
Myelocytes (with peri-nuclear halo)
Left-shifted neuts
Monocytes
Rbc (in order of priority)
Basophilic stippling
Nucleated rbc
stomatocytes
Polychromasia
Target cells
Anisocytosis
Plt
reduced
Vacuolated neuts
Dohle body
Myelocytes (with peri-nuclear halo)
Left-shifted neuts
Monocytes
Rbc (in order of priority)
Basophilic stippling
Nucleated rbc
stomatocytes
Polychromasia
Target cells
Anisocytosis
Plt
reduced
I felt that this was possibly a case of sepsis (or Jordan's anomaly) in someone with a haemolytic condition. And I said that “without more information any further speculation is frankly guesswork”.
The final report said “It is certainly possible that the polychromasia and nucleated cells reflect a bone marrow response to red cell destruction. However, the abnormal erythrocyte forms present are not typical of red cell fragmentation, membrane disorder, or abnormal haemoglobin. We should therefore consider that bone marrow infiltration (particularly a myelodysplastic syndrome) may be present causing the expulsion of immature and maturing”…
“This is a patient with chronic myelomonocytic leukaemia who had experienced a deterioration in his health following an infection. The features have been described in the narrative, but the diagnosis is not simple. Without full knowledge of the number of monocytes, and a review after the infection is resolved, it is not possible to be fully confident that this is chronic myelomonocytic leukaemia. However, the extensive dysplastic features present should allow a diagnosis of probably underlying myelodysplasia; and a possible diagnosis of CMML could be suggested”.
I spotted the salient features which could equally well be applied to what I thought it was as well as what it supposedly was.
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