28 January 2022 (Friday) - 2106 DM

I had a look at NEQAS digital morphology exercise 2106 DM on 16 November and was presented with: 

 “This is an image from a blood film prepared from a 67-year-old female known to have mild anaemia and an enlarged spleen. At a routine clinic follow up she was found to have a rising white cell count. You are asked your opinion. This case has complex morphology so you may wish to look at our help pages” 

Well… the red cells were horrible. Anisopoikilocytosis with echinocytes, tear drop cells, red cell fragments. Spherocytes and nucleated red cells with polychromasia. 
The white cells were equally yuk, with degenerate neutrophils, myelocytes and blast cells. Odd-looking monocytes, smear cells and what I can only call “bi-lobed strange things”. One might have been a Pelger-Huet neutrophil. but the others looked lymphoid.
There were giant platelets and grey platelets  and were a couple of the odd things megakaryocytes?

As for the clinical condition… I would hazard a guess at myelodysplasia considering transforming into leukaemia… but that’s just a guess. Quite frankly if this appears down the microscope it gets referred to the haematology consultant whose patient it already is. 

 The results were available to me today. 

“This is a leucoerythroblastic picture with marked red cell abnormalities and tear drops cells in a 67 year old female with splenomegaly.  The original diagnosis was of JAK2 positive PRV but the features are much too abnormal to support this as a sole diagnosis. In fact, at the time of this film the disease was transforming to myelofibrosis (the presence of tear drop forms, early erythroid progenitor cells, a bare megakaryocyte nucleus are suggestive of this transformation). The primitive cells present on the film may be a reflection of the advanced fibrosis, but in this case were found on bone marrow examination to reflect an additional transformation to an acute leukaemia,”

Leukaemic transformation… I got that right.