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.

24 December 2020 (Thursday) - BTLP Excercise

Time for another BTLP-TACT exercise – it has been a couple of weeks and the boss told me off for not getting on with it… 

I was presented with one case – a seventy-four year old woman going for surgery the next day requiring four units of blood. 
She grouped as AB Rh(D) Positive with antibody screen positive in cells 1 & 2. 
I requested antibody panels. 
The IAT panel was positive in cells 2 3 5 7 9 and the enzyme panel was negative in all cells 
This looked very like anti-S but I couldn’t rule out anti-E or anti-Lua..  It would have been good to have been able to see the screening antigram but the software wouldn’t allow it. 
I ruled out anti-E as this antibody didn’t react by enzyme. 
I selected four S-negative units…

I got the red light. Apparently the anti-Lua wasn’t there… had I been able to see that antigram… 
I’m taking that as a green light…  

The problem here is one I’ve encountered before. In reality I can see the antigrams for screen and panel at the same time. However in the simulator once I’ve said “positive” to the antibody screen I can’t see the antigram for it any more…

I need to rule stuff out at the point of doing the screen (which isn’t what happens in reality) or take screen shots (which is a faff).

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…