SBMHEMATOLOGY

November10,2015

SEMINARQUANTITATIVEANDQUALITATIVEDISORDERSOFWBC

Reading:Hoffbrand,PettitandMoss,ch.9,10,11,13and17.
CASE1
Youareaskedtoseea68yearoldmanadmittedonthesurgicalserviceforrepairofanumbilicalherniawhena
routineCBCshowsalowWBC.Theresidenttellsyouthatthepatientisgenerallywellbutnotesapneumoniathat
was treated as an outpatient with po ampicillin three months ago and more recently had right arm cellulitis
successfullytreatedwithcephalexin.Thecourseofantibioticswascompleted3daysago.Healsonotesincreasing
fatigueoverthelastthreemonths.Pastmedicalhistoryisnotableforprostatecancertreatedwithradiationtherapy
5yearsagowithoutevidenceofrecurrence.
HisWBCis2K/cmm*,with10%neutrophils,3%bands,and87%lymphocytes.
1.

Howdoyoudetermineifthepatienthasenoughneutrophils?

2.

Whatisyourdifferentialdiagnosisforhisneutropenia?Whatarethemechanismsofneutropenia?

Youmeetthepatient.Heisawelldevelopedmaninnoapparentdistress.
Pastmedicalhistoryincludes:
- Atrialfibrillationcontrolledwithamiodaronefor3years.
Socialhistory:
- Worksasahighschoolteacher
- Noalcoholabuse,nohistoryofsmoking,nopriorexposuretotoxicsubstances
- Married;hastwohealthychildren
Thephysicalexamisnegativeexceptforsomescatteredpetechiaeonhisextremities(imagebelow).Stoolisheme
negative.

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RevisedSeptember2011

December16,2015

SeminarQuantitativeandQualitativeDisordersOfWBC

Laboratory(referencevaluesinparentheses):
Whitebloodcellcount:2(4.5to11.0)K/cmm
Hemoglobin:10.2(14to18)g/dl
Hematocrit:30.6(40to52)%
MCV:98(8098)fl
Redcelldistributionwidth:13(11.514.5)%
Plateletcount:25(130to450)K/cmm
LYMPHOCYTES:87(1055)%
NEUTROPHILS:10(4075)%
Reticulocytes:1%
LFTs:normal
Reviewofhisbloodsmear:

3.

Howdoesthishelptonarrowthedifferentialdiagnosis?

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4.

Whatisthenextbesttest?

5.

Whilewaitingforthetestresults,thepatienthasafeverto103withrigors.HecomesintotheERwithno
specificcomplaintsexceptforthefever. Physicalexam,UAandCXRarenormal. Hewantstogohome.
Whatareyourrecommendations?

6.

Thebonemarrowcomesbackhypercellularwithevidenceoftrilineagedysplasiaand3%blasts.Whatishis
disease?Whatishisprognosis?Whatarehistreatmentoptions?

7.

HeoptsforsupportivetreatmentandisdoingwellwithRBCtransfusiononly.Threemonthslaterhepresents
backtoyourofficewithsomechestpainandcoughwithoutfever.ACXRshowsalargemassintheRUL
(imagebelow).Whatisyourdifferentialdiagnosis?

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SeminarQuantitativeandQualitativeDisordersOfWBC

8. YoudecideyouwanttomakethediagnosiswithaCTscanguidedneedlebiopsy.Theradiologistasksyouto
makesurehiscoagulationstatusissafe.TestscomebackwithPT,PTTandPltcountnormal.Whatdoyoutell
theradiologist?

9.

Hedoesverywellwithempiricantifungaltreatmentanddecidestoreceive5azacitadine.Howdoesitwork?

10. Ayearlateryouseehimagainbecausehistransfusionrequirementshaveincreased.CBCshowsaWBCof
10Kwith2%neutrophils,10%lymphocytesand88%blasts,pltsof15KandHgbof8(imagebelow).What
hashappened?Whatistheprognosis?

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SeminarQuantitativeandQualitativeDisordersOfWBC

*
TestnameRef.range
WBC
4.511.0K/cmm
RBC
4.76.1M/cmm
HGB
1418g/dl
HEMATOCRIT 4052%
MCV 8098fl
MCH 2734pg
MCHC 3237g/dl
RDW 11.514.5%
PLT 130450K/cmm
MPV 7.40.4
COULTERLYMPH
1055%
COULTERMONO
212%
COULTERGRAN
4075%
COULTEREOS
107.0%
COULTERBASO
02.0%

CASE2
A25yearoldwomanisreferredtoyourofficebecauseofleukocytosisdiscoveredbyCBCcollectedduringa
routineevaluationforhernewjob.Shehasahistoryofrheumatoidarthritisdiagnosedattheageof20whenshe
presented with symmetrical metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints MCP
(metacarpophalangeal)jointswelling.

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SeminarQuantitativeandQualitativeDisordersOfWBC

Overthelast5yearsshehashadmultipleflaresaffectingdifferentsmallandlargejoints.Shehasbeentreatedwith
NSAIDs,methotrexateand,morerecently,prednisone.Sheiscurrentlyonprednisone5mg/dayonly.Shenotes
thatherhandshurtabitbutgenerallyshehasbeendoingwell. Shedeniesconstitutionalsymptoms. Physical
exam is notable for bilateral synovial thickening in her wrists. There is no lymphadenopathy or
hepatosplenomegaly.
Labs:
Testname

Ref.range

WBC
HGB
HEMATOCRIT
MCV
RDW
PLT
COULTERGRAN
COULTEREOS
BANDS
METAMYELOCYTES

25
14
42
89
13
500
70
2

4.511.0K/cmm
1418g/dl
4052%
8098fl
11.514.5%
130450K/cmm
4075%
107.0%

10
1

Rheumatoidfactorisstronglypositive,ESR7
1.

Doesshehaveleukocytosis?

2.

Ifso,whatkindofleukocytosisdoesourpatienthave?

3.

Whyisitimportanttodeterminewhatkindofleukocytosisthepatienthas?

4.

Whatisthedifferentialdiagnosisofherneutrophilicleukocytosis?

Herspleenisnonpalpableandherperipheralbloodsmearlookslikethis:

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SeminarQuantitativeandQualitativeDisordersOfWBC

5.

Whatisyourmainworkingdiagnosisnow?

6.

Whatisthenextdiagnosticprocedure?

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7.

Afterfurtherdiscussions,shehasabonemarrowdone,whichishypercellularwithanM:Eratioof6:1.All
cell linesarepresentandmaturing. Therearelessthan5%blastsandthereisnodysplasia,infiltrate,or
fibrosis.Doesthishelpyoumakeadefinitivediagnosis?Isthereanyothertestthatmighthelp?

8.

ThecytogeneticsrevealsaPhiladelphiachromosomeandsheisdiagnosedwithCML.Whatisthebiological
significanceofthePhiladelphiaChromosome?

9.

Whatisthenaturalhistoryofthisdisease?Whatarethetreatmentoptions?

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10. The patient decides to proceed with dasatinib, which induces a complete response (she becomes bcrabl
negative).Fiveyearslater,herWBCstartsrisingandaPCRforbcrablconfirmsrecurrentdisease.Asecond
linetyrosinekinaseinhibitorisinitiated,whichworkswell,butthreeyearslatersherecursagain.Whatisthe
nextlineoftreatment?

*
TestnameRef.range
WBC
4.511.0K/cmm
RBC
4.76.1M/cmm
HGB
1418g/dl
HEMATOCRIT 4052%
MCV 8098fl
MCH 2734pg
MCHC 3237g/dl
RDW 11.514.5%
PLT 130450K/cmm
MPV 7.40.4
COULTERLYMPH
1055%
COULTERMONO
212%
COULTERGRAN
4075%
COULTEREOS
107.0%
COULTERBASO
02.0%

111015_SG_Case1