26 October 2021 (Tuesday) - A Discussion

A colleague asked if I had a spare few minutes today… I did, and together we sat and looked through a e-Haematimage case study.
I really did enjoy doing it.

Morphology EQA seems to follow the same format these days… someone at NEQAS HQ manages to track down the most obscure case, provide us with rather poorly made and poorly stained blood films, minimal clinical information and pretty much no laboratory data whatsoever. From this we are supposed to guess whether we’ve got a case of Bendii syndrome, xenopolycythaaemia or Andorian measles (forgive me if I appear a tad frustrated).

But today’s case was excellent. We were given full clinical information, full laboratory data, and clear pictures of individual blood cells and of fields of a blood film. Like we would be given in real life.
It turned out that the case was one of Burkitt’s lymphoma. I learned a lot about that specific condition (learned or remembered stuff I’d forgotten – not sure which!) but it was so good to sit with someone and discuss the case. Was that a blast cell? If yes, we said why it was. If no, we said why not. What is the difference between a myelocyte and a promyelocyte? Why is that ?

I spend so much time looking at blood films.. and pretty much all of that time is on my own. Back in the day we used to have morphology workshops. I wonder if we might have those again?

30 December 2020 (Wednesday) - e-haematimage 20.08

20.08     A 70-Year-Old Man with Fever, Fatigue and Dyspnoea of Recent Onset 

Again my colleague had already done the diff, but she pays for it and I am in no way complaining. I felt the diff was 98% lymphocytes and 2% neutrophils 
I felt the diagnosis was CLL (Chronic lymphocytic leukemia) with a haemolytic anaemia  
The obvious next step was to perform direct antiglobulin test (DAT), a reticulocyte count and lymphocyte subtyping 

To answer the questions: 

1 Comment on the results of the erythrocyte indices. 

The MCV is very raised and haemoglobin very low.  
The red cell indices show an implausibly low MCHC suggesting something awry in the red cell indices measurements/calculations.   

2 In view of all the laboratory findings, how do you explain the abnormalities of the erythrocyte indices? 

The RBC histogram shows that a population of huge (relatively) cells is present.  
Red cells and white cells are counted together by the impedance technique which does not cause issues at usual levels of white cell count. However when the white cells count is  high it can cause an erroneous overestimation of the red cell count and mean cell volume and consequently haematocrit. 
Thus the MCHC is calculated wrongly (i.e. very low) 

3 Which results of the blood count do you think are really informative? Would you validate them? 

These red cell results are not accurate (i.e. wrong). The sample should be diluted and re-analysed.   

4 What is the most likely mechanism of this patient’s anaemia? (The answer to this question must not be repeated in the diagnostic hypotheses.) 

The presence of polychromasia and spherocytes suggest a possible haemolytic anaemia. 

 I did ok… not sure I understood the last question though...

24 December 2020 (Thursday) - e-HEMATimage case studies

e-Hematimage 20.06 A 74-Year-Old Man with Pale Skin and Mucosa

The white cell differential  was unremarkable, but the red cell morphology showed hypochromia  and microcytosis with pencil cells and occasional target cell seen  

To answer the questions asked:

1 Describe the results of the blood count. 
Hypochromic microcytic anaemia

2 What cytological abnormalities on the blood film do you think are useful for diagnosis?
Hypochromic microcytic red cells with pencil cells and occasional target cell seen

3 In this context, do you think it is relevant to add a reticulocyte count?
Yes

4 The patient was not in a fasting state and must return to the laboratory the next morning to complete the check-up tests. Would you advise his treating physician to request further tests? If so, what tests would you suggest?
Iron studies – serum iron, TIBC (I’m old-skool!) and ferritin. It’s always worth checking the B12 & folate in these cases as a deficiency of those may well be masked by the iron deficiency

I did good…

e-Hematimage 20.07 A 2-Year-Old Male Child with Down Syndrome and a High White Blood Cell Count  

The white cell differential was horrible – loads of blast cells with just a few lymphocytes and only  a single neutrophil there

To answer the questions asked:  

1 What are the most significant findings associated with this patient’s full blood count and differential?
Leucocytosis – loads of blast cells with thrombocytopenia and anaemia

2 Describe the predominant leucocyte population. Considering the patient´s genetic condition, how would you classify these cells and what diagnosis seems more likely?
Blast cells - AML

3 How would you classify the cells presented in the image wall (continued)?
Yuk ! (in all honesty)

The diagnosis was either 
1. Myeloid leukaemia associated with Down syndrome
2. Acute megakaryoblastic leukemia (WHO) = M7 (FAB)  

I think I did OK – in such a case I would know to sound the “Red Alert” (!) I’d spotted the cytoplasmic blebs – I hadn’t realised that these are a feature in acute megakaryoblastic leukemia… but I do now.  I’ve learned something here, and as it says at the top of this page, a day when you learn nothing is a day wasted.

23 december 2020 (Wednesday) - More e-HEMATimage case studies

With a few moments spare today I looked at two e-HEMATimage case studies 

e-HEMATimage case study 20.04

On reading the title “18-Year-Old Man with Sore Throat, Headaches and Low Grade Fever” I immediately thought “Glandular Fever”… it’s the old “horses, not zebras” mantra. And clearly in this case it was a horse… with a zebra in there too.  

My colleague had got to the presentation before me and had done the diff – next time I must get there first – but seeing how she is paying for it and is being good enough to let me play I am in no way complaining. I went through the diff count – I agreed with most of the cells classifications but I think that I would have called more of the “normal” lymphs to be atypical.

It was only on having another look at the atypical/normal lymphs that I spotted the target cells… and the red cells – were they a tad small?
This was a case of glandular fever in a (transfusion-dependent) chap with beta thalasaemia major. 

e-HEMATimage case study 20.05 - “75-Year-Old Man in Poor General Condition”

My colleague had again got to the presentation before me and had done the diff – next time I really must get there first – but seeing how she is paying for it and is being good enough to let me play I am in no way complaining. I went through the diff count – I agreed with most of the cells classifications but I must admit I was a tad vague between what was classified as a plasma cell and what was classified as a lymphocyte. The plasma cell has more cytoplasm, and is darker… Generally…

The questions posed:  

Describe the predominant leucocyte population. Considering the medical history, how would you classify these cells?

 The main leucocyte population is of lymphoid lineage, predominately plasma cells  

Are there any abnormalities in the red blood cell morphology that are useful for diagnosis? .  

Rouleaux seen on the blood film is in keeping with increased plasma proteins.

Are there any abnormalities in the biochemical laboratory tests results that are useful for diagnosis?  

Raised plasma calcium and urea could be in keeping with bone destruction

 

 I think I did OK…