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.

20 April 2026 (Monday) - NEQAS 2505DM

I got the results of NEQAS 2502DM today…

 

“This film was prepared from the blood of a 73-year-old man who attended the Emergency Department after experiencing increasing tiredness, then more recently bleeding from his gums. His white cell count was found to be elevated, and a blood film was prepared. What is your opinion of the blood film appearances?”

 

Bleeding from gums immediately makes me think “thrombocytopenia”  but that isn’t the case. There’s platy of platelets. Some are clumped and some rather large.

The red cells are on the whole rather dull. There’s a Howell-Jolly body and a target cell there.

But it’s the white cells that are odd here. Too many of them, and precious few of them “normal”. There’s smear cells, dysplastic neutrophils, vacuolated monocytes, and blasty-looking things.

Is this a case of MDS?

I pressed the button before I could comment…

 

The expert opinion said CLL…  seriously?

 

2 April 2026 (Thursday) - NEQAS 2602 BF

I got the results of NEQAS morphology survey 2602BF today…

 

2602BF1 I said:

 

Hypochromia (consensus 4^th)

Target cells  (consensus 1^st)

Large plts (consensus 2^nd)

Neutropenia (consensus 14^th)

 

I wrote “? thal ? SC disease”. The expert opinion said: “These features are all suggestive of Hb SC disease and this was confirmed on HPLC though the degree of microcytosis should lead to the consideration of a coexistent alpha thalassemia trait”

 

 

2602BF2 I said:

 

Hypochromia (consensus 1^st)

Microcytosis (consensus 2nd)

Pencil cells (consensus 3^rd)

Tear drop cells (consensus 5^th)

^ plts (consensus 4^th)

 

I thought this was a case of iron deficiency. It was.

 

9 March 2026 (Monday) - NEQAS 2601DM

 

I got the results of 2601DM this morning. I did it a month ago when I was presented with an image of a blood film and this statement:

 

“A 60-year-old man had commenced treatment for a serious haematological disorder. His white cell count was raised, and platelet count reduced. He then became increasingly anaemic with changed blood film features. You are asked for your opinion. The film arrives outside of normal hours”

 

In my notes I wrote “Well, there’s a bit of everything in this film, isn’t there. The red cells show echinocytes, microspherocytes, blister cells, nucleated red cells, Howell Jolly bodies, rec cell fragments.

The white cells are a bit of a disaster – cerebriform/flower type lymphocytes, toxic granulation, vacuoles in monocytes and neutrophils, smear cells, target cells, pyknotic neutrophils, eosinophilia. 

The platelet appeared reduced, but we were told that anyway.

 

I didn’t fiddle about trying to get the observations in order… time was pressing.

As this arrived out of normal hours I would put it for the consultant to review in the morning… they don’t thank us for being bothered about this sort of thing… this sort of thing being a patient of which they are already well aware”.

 

The expert opinion was rather odd… it waxed on as it so often does but seemed to completely overlook the fact that this was in a patient with a known haematological condition.

But I spotted that which needed spotting and made the right decision

5 March 2026 (Thursday) - NEQAS 2601 BF

I got the results of NEQAS morphology 2601BF today
 
2601 BF1
 
302   Thrombocytopenia (consensus 1^st)
212      Blast cells (consensus 2^nd)
012   Red cell fragments (consensus 3^th)
213   Promyelocytes (consensus 4^th)
022   NRBC (consensus 5^th)
 
I said ?? acute promyelocytic leukaemia. It was.
 
2601 BF2
 
212      Blast cells (consensus 1^st)
224   Basophilia (consensus 2^nd)
022   NRBC (consensus 3^th)
301   Thrombocytosis (consensus 4^th)
213   Promyelocytes (consensus 8^th)
 
I said ?? CML transforming. It was certainly something transforming, but the expert opinion was rather vague as to what.

 

5 March 2026 (Thursday) - NEQAS 2601 PA

I got the results of NEQAS parasitology 2601PA today
 
2601 PA1
 
I said this was P Falciparum with trophozoites and a parasitaemia of 0.5%
I got the species and the parasitaemia right
 
2602 PA2
I said this was Microfilaria (loa loa)
It was.

20 January 2026 (Tuesday) - NEQAS 2506DM

I finally got the results of NEQAS 2506DM forty-two days after it closed. At the time (8 December 2025) I said “Well, there’s something haemolytic going on, isn’t there? Schistocytes, red cell fragments, nucleated red cells, polychromasia, ghost cells, spherocytes and were there some occasional odd red cell inclusions?

The platelet count was down (well, we were told that) and there were some large platelets.

There was one myelocyte and a couple of dysplastic neutrophils”

 

It turns out this was a case of TTP; I spotted that which I needed to spot. Interestingly the expert opinion made no mention of the myelocyte or dysplastic neutrophils.

 

As time goes by I find myself getting more and more frustrated with NEQAS morphology. Bearing in mind they know what the cases are when they go live there is absolutely no reason at all why we should have to wait six weeks for feedback on something about which I have by now totally forgotten…

6 January 2026 (Tuesday) - NEQAS 2508 BF

I got hold of the results for NEQAS 2508BF today…
 
2508 BF1
 
I said:
 
Lymphocytosis (consensus 3^rd)
smear cells (consensus 4^th)
Thrombocytopenia (consensus 1^st)
Abnormal Lymphs (consensus 6th)
 
I felt this was CLL – it was.
 
2508 BF2
 
I said:
 
Myelocytes (consensus 3^rd)
Promyelocytes (consensus 4th)
Nrbc (consensus 2^nd)
Blast cells (consensus 5th)
Thrombocytopenia (consensus 1^st)
 
I felt this was CML. The expert opinion was uncertain. Had this appeared in real life I would have referred it anyway…

3 December 2025 (Wednesday) - NEQAS 2507 BF

I got hold of the results of NEQAS 2507 BF today…

 

2507BF1

 

I wrote

 

Hypochromic (consensus 1^st)

Microcytic      (consensus 3^rd)

Pencil cells    (consensus 4^th)

Target cells   (consensus 2^nd)

Tear drop cells (consensus 6^th)

 

I wrote ?? Fe def. The expert opinion said “2507BF1 was the blood film from a 23-year-old woman with iron deficiency anaemia,”

 

 

25007BF2

 

Macrocytosis (consensus 4^th)

HJB

Tear drop cells (consensus 6^th)

Hypersegmented neut (consensus 1^st)

Low plts (consensus 3^rd)

 

I wrote ?? B12 def The expert opinion said “2507BF2 was the blood film from a 56-year-old man with nutritional megaloblastic anaemia”

 

I’ll take that…

 

3 December 2025 (Wednesday) - NEQAS 2504 PA

I got hold of the results of NEQAS 2504 PA today…

2504 PA1

This was “the thin blood film from a patient of unspecified age and sex and with an unknown travel history. It showed a heavy (2.1%) infestation with Plasmodium knowlesi malaria”.  

I wrote “P falciparum - rings, trophozoites & shizonts 5% parasitaemia”. I got the species wrong and overestimated the parasitaemia, but I spotted malaria.

2504 PA2

The expert opinion said “There were no parasites to see on this thick film” 

I wrote “Think it's negative. Saw one iffy thing”

 

I’ll take that…

21 October 2025 (Tuesday) - NEQAS 2505 DM

I got the results of NEQAS 2505DM today. The case gave me a blood film and said:

 

“A 72 year old man attended the Emergency Department overnight with symptoms of a chest infection. An initial blood count showed a normal haemoglobin, neutrophil count and platelet count. However, the white cell count was significantly elevated with a marked lymphocytosis.

The analyser suggested the lymphocytes may be neoplastic. You are asked to examine the film and see if there are any immediate clinical concerns. What is your view?”

 

I can’t remember much about it, but my notes were:

 

“The neutrophils, platelets and red cells all look OK to me.

The lymphocytes are pleomorphic (all different) with smear cells.

This is CLL and should be referred to the consultant, but not with any immediate urgency”.

 

The expert opinion was:

 

“Making a definite diagnosis of chronic lymphocytic leukaemia can be tricky, especially during the night, but having the confidence to offer that reassurance to clinicians can make a big difference that prevents concern about other diagnoses. In this case, the normal haemoglobin, neutrophil and platelet counts are very reassuring, and the morphological features are fairly typical of the disorder. Faced with these decisions, it is important to look at the overall features rather than focusing too strongly on occasional cells that might not fit perfectly with your opinion. Particularly when the normal cells are well represented, it is often appropriate to give your preferred diagnosis even when waiting for formal confirmation the next morning. CLL can have varied morphology, but the appearances shown in this case are fairly typical”.

 

I’m taking that as a result…

7 October 2025 (Tuesday) - NEQAS 2506 BF

I got the results of NEQAS 2506 BF today…

 

2506 BF1 was in my opinion unremarkable. It was the blood film from a healthy 53-year-old woman who had a full blood count as part of pre-operative assessment before routine elective surgery. The numerical parameters of the full blood count were all within normal limits, as were the blood film appearances.

2506 BF2 I said:

 

Fragments (Consensus finding #1)

Thrombocytopenia (Consensus finding #2)

Acanthocytes (Consensus finding #4)

Hypochromic/polychromatic (Consensus finding #3) 

Spherocytes (Consensus finding #6)

 

This was the blood film from a 57-year-old man with a Thrombotic microangiopathy (TMA) – i.e. the combination of a microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia.

 

One needed action, one didn’t. I spotted the salient features. I’m claiming that as a result.

29 September 2025 (Monday) NEQAS 2504 DM

I got the results of NEQAS 2504 DM today. I can’t remember anything about it, but my notes said “Neutropenia, thrombocytopenia, blast cells, promyelocytes, myelocytes, folded nuclei... ? Sezary”

The expert opinion said:

“Acute promyelocytic leukaemia with many cells resembling the typical hypogranular form of the disorder; but notice also the variable forms present that reflect orientation of cells on the slide, but also the slightly varying maturation of the abnormal cells that is typical of the disorder”.

 

Well… I got that wrong. Or did I? I spotted the salient features and would have referred it urgently.

It’s interesting that the expert commentary didn’t mention the folded nuclei…

15 September 2025 (Monday) - NEQAS 2505 BF

I got hold of the results of NEQAS 2505BF today…In my notes for BF1 I wrote
 
Rbc 
 
NRBCs
Howell Jolly Bodies
echinocytes 
anisopoikilocytosis
 
Wbc
 
Lymphocytosis
Hypersegmented neuts
 
Plts
 
Thrombocytosis
 

I spotted the salient features (if the consensus view was correct) but I am shouting “I Told You So!!” very loudly as the expert opinion started off by saying “There is a problem with this case as there is a lack of clinical information” and then went on to list no end of possible diagnoses.

I’ve always said that asking us to give a diagnosis on the strength of incredibly limited information is very unreasonable, and the expert opinion would seem to be agreeing with me.

 
For BF2 I said:
 
Rbc
 
NRBCs
Polychromasia
Target cells
Blister cells
 
Wbc
 
Neutrophilia
myelocytes
blast cells
 
Plts
 
thrombocytopenia
 
The blister cells had me thinking of a G6PD deficiency, but what were the blast cells all about?
The expert opinion felt this was either G6PD or an unstable haemoglobin. Bearing in mind that unstable haemoglobin is into rocking horse poo territory, I’m claiming that as a result.

10 September 2025 (Wednesday) - NEQAS Parasitology Result

I got hold of the results of NEQAS survey 2503 PA today.

 

2503 PA1 – I wasn’t convinced. I didn't say negative… but I’ve never found thick films easy. When I was first taught malaria identification over forty years ago I was told how difficult it is to distinguish between genuine parasites mangled by the cell lysis and cell debris mangled by the cell lysis.

There was actually P. falciparum in there – I shall have another look.

2503 PA2 – I saw P. falciparum. I was right. I estimated a 1% parasitaemia; a parasitaemia wasn’t reported

I'll take that .

29 July 2025 (Tuesday) - 2503DM

 

I got the results of 2503DM today. At the time (30 June) I wrote “Well, there’s malaria there. I’d go with a mixed infestation. P.vivax and P. malariae”.

I was right in that there was malaria there. But I was wrong in that it wasn’t mixed. It was just P. malariae. However I’m taking that as a result. I spotted the malaria which is the important part. Speciation is something that I would sent off to the reference lab anyway, and I don’t think I’ve ever actually seen P. malariae outside of a EQA slide.

16 June 2025 (Monday) - NEQAS 2502 PA

The results of NEQAS 2502 PA became available today. It gas to be said that I wasn’t overly confident on that survey.

 

2502 PA1 was a thick film. I said “Parasites present”. There were – P. Knowlesi. The expert opinion said  “It is optimistic to hope to distinguish between different species of Plasmodium on a thick film unless you are working in a high prevalence area or have extensive experience”.

 

For 2502 PA2 I said “ring forms” and there was. The expert opinion said “This is an example of babesiosis, most likely due to Babesia microti. It was a difficult film to interpret. B. microti is mainly seen as small rings, so it is easily confused with Plasmodium sp”.

 

In both cases I spotted parasites present. Obscure ones that I rarely, if ever (never), see in practice. But I spotted them. Had this happened in reality the case would be referred to a specialist lab.

I’m taking this as a success

7 June 2025 (Saturday) - NEQAS 2503 BF

I got the results of NEQAS 2503BF today.

 

For NEQAS 2503 BF1 I felt the red cells were unremarkable. The white cells showed blast cells, folded nuclei, cytoplasmic blebbing/hairy cells and neutropenia. The platelet count was reduced.

I spotted the salient features – the patient had AML.

 

For NEQAS 2503 BF2 I felt the red cells showed anisopoikilocytosis with nucleated red cells, target cells and burr cells seen. The white cells showed neutrophilia and monocytosis (with vacuolation). Some cells showed cleft nuclei  and clover leaf nuclei. I spent a while before deciding these were not Sezary cells. There were also smear cells there.

The platelet count was reduced.

I spotted the salient features – the patient had CMML.

6 May 2025 (Tuesday) - Feeling Smug

I got the results of NEQAS 2502 DM today. My notes said:
 

• Falciparum - ring forms & gametocytes
• Ovale schizonts (as fimbrillation) on red cells
• ??? exflagellation
• Unusual Wbc

 
The expert opinion said:
 
“This case shows a dual parasite infection with P. falciparum and P. ovale. Cases such as this are infrequent but certainly seen. The key is to recognise when things don’t quite match those of a single species. Present on this film are early trophozoites of P. ovale, late trophozoites of P. falciparum, and gametocytes of each species. There is a phagocyte containing malaria pigment.”
 
Well, I spotted the two species correctly, and the “unusual Wbc” I saw would be the one with the malarial pigment. Bearing how infrequently we see positive malarial smears, let alone ones with dual infestations, as Kryten 2X4B 523P would say “engage smug mode”…

2 April 2025 (Wednesday) - NEQAS 2502 BF

I got hold of the results of 2502 BF today.

 

I said:

 

2502BF1

 

Lymphocytosis   (consensus 3^rd)

Bi-lobed lymphocytes (consensus 7^th)

Smear cells (consensus 1^st)

Neutropenia (consensus 5^th)

Thrombocytopenia (consensus 4th)

 

I thought this was a lymphoproliferative condition. It was CLL

 

2502BF2

 

Neutropenia (consensus 3^rd)

Reactive/atypical lymphocytes (consensus 2^nd)

Smear cells (consensus 9^th)

 

I thought this was a lymphoproliferative condition. Apparently it was glandular fever… several of us sat down with one of the consultants and we were unanimous that it wasn’t.

Just goes to show you can’t rely on morphology alone.