16 July 2026 (Thursday) - Learning Monday (three days ago...)

 

The correct answer is option 4. Heatstroke 

The cells depicted are neutrophils (A-D), lymphocytes (E) and monocytes (F) with botryoid nuclei, characterized by hypersegmented nuclei with a radial arrangement. These were first seen in 1980 in six patients with heatstroke and were named after the Greek term “botrys,” which translates onto “bunch of grapes” because of their resemblance. Since then, they have been described in other conditions causing severe hyperthermia, such as cocaine and methamphetamine abuse, autoimmune limbic encephalitis, sepsis, drug rash with eosinophilia and systemic symptoms (DRESS) and neuroleptic malignant syndrome. These nuclear changes have been hypothesized to be early stages of oncotic (karyolysis) and apoptotic (karyorhexis and pyknosis) cell death because of extreme heat.

Reference: 

• Verdú G, Vallvé M, San-José P, Molina A, Merino A. Diagnostic Value of Botryoid Nuclei as a Biomarker of Severe Hyperthermia and  Systemic Inflammation in Heatstroke and Neuroleptic Malignant Syndrome: A Challenge of Climate Change. Int J Lab Hematol. May 2025. doi:10.1111/ijlh.14500 

• Chiriac R, Pourchet V. Noyaux botryoïdes des leucocytes induits par le syndrome de DRESS. Ann Biol Clin (Paris). 2025;83(2):220-222. doi:10.1684/abc.2025.1961 

14 July 2026 (Tuesday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. I had one case – a seventy-seven year-old woman needing two units of blood for a haematemesis. She grouped as B Rh(D) Positive with antibody screen positive in cells 2 & 3. I performed antibody panels.

The enzyme and IAT panels were positive in cells 1, 3, 4, 6 & 7 corresponding with anti Jk(a). I selected two unts of blood that were Jk(A) negative (one O Rh(D) Pos, one B Rh(D) Pos)

I got it right.

 

6 July 2026 (Monday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. I had one case – a twenty-one year-old woman from the ante-natal clinic needing group and save.

She grouped as B Rh(D) Positive… was that supposed to be a weak reaction with the D? Bearing in mind the issues I’ve had with BTLP-TACT in the past I erred on the side of caution and called it inconclusive and said I would send it to NHSBT.

The antibody panel was negative though. 

I got it right - that was supposed to be a weak reaction.

5 July 2026 (Sunday) - NEQAS 2603 BF

I got the results of NEQAS 2603BF today.
 

For 2603 BF1 I said

 

Hairy cells  (consensus 1^st)

Lymphocytosis (consensus 4^th)

low plts (consensus 3rd)

Neutropenia (consensus 5th)

NRBC (consensus 2^nd)

 

I thought it was hairy cell leukaemia. It was.

 
For 2603 BF2 I said
 

Neutropenia (consensus 4^th)

low plts (consensus 1^st)

Blast cells (consensus 2^nd)

“iffy” lymphocytes (consensus 6^th)

Rouleaux (consensus 5^th)

 

I thought it was “???”. It could have been any of a wide range of conditions. The expert opinion said “In essence the morphology, in isolation, suggests a wide differential diagnosis”.

 

I’ll take that…

 

5 July 2026 (Sunday) - NEQAS 2602 PA

I got the results of NEQAS 2602PA today.
 
2602PA1: Microfilaria of Loa Loa
2602PA2: Negative for malaria

 

That’s what I said.

1 July 2026 (Wednesday) - Cladribine

I had a patient with an unexplained neutropenia today. The diagnosis was “multiple sclerosis on cladribine”.

Taken orally as Mavenclad, it is prescribed for adults with active relapsing-remitting multiple sclerosis to reduce the frequency and severity of relapses. However Cladribine is also used in lymphoid neoplasms. It mimics the nucleoside deoxyadenosine but resists breakdown by the enzyme adenosine deaminase, causing it to accumulate inside lymphocytes and interfere with DNA synthesis and repair.

Common side effects include a reduced white blood cell count and an increased risk of viral infections such as shingles or oral herpes.

And it can cause neutropenia too.

 

30 June 2026 (Tuesday) - Fritsma Factor Update

The nice people at the Fritsma Factor sent out their newsletter today. You can read it by clicking here. There was quite a bit to take in. Sickle cell, lupus, Von Willebrands….

It’s a rather good source of CPD…