16 September (Friday) - C.M.L.

Another on-line morphology exercise. A man aged 59, was referred by his family physician for a haematology consultation for investigation of weakness and leukocytosis. The patient had an unremarkable past medical history. He was a former policeman, now retired. He had led a normal life, remaining physically active and practicing sports on a weekly basis. A couple of weeks previously he began developing progressive weakness. Physical examination showed an enlarged spleen, 6 cm from the costal margin. Besides the blood count, other tests carried out including renal and liver function which were normal; only C-reactive protein (211 mg/L) and lactate dehydrogenase (980 IU/L) showed elevated levels.

The on-line blood film showed neutrophilic leukocytosis and the presence of granulocyte precursors, eosinophilia and marked basophilia (20.0%).
Occasional micromegacaryocytes were present with their striking features of evenly distributed cytoplasmic blebs. My differential wasn’t as spot-on as it might be, with me and the expert disagreeing on pre-myelocytes and blast cells. But in many ways, that’s me being picky.

Whilst a slight increase in the number of basophils may be associated with various diseases, marked basophilia is usually associated with myeloid neoplasms, including myeloproliferative neoplasms (MPN), acute leukaemia and myelodysplastic syndromes (MDS).

Basophilia together with neutrophilic leukocytosis and the presence of neutrophil precursors immediately pointed to chronic myeloid leukaemia. I gave that as my answer – I was right. 

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