Hematology Case # 1

History of Present Illness

The patient was a 47-year-old white male who was seen in the clinic, with the complaint of weakness and fatigue. He had loss of appetite. He had lost 10 pounds in the past month, felt weak and was bed ridden. The patient was dizziness on standing. His Temp was 36.8 degrees.

Hematology Case # 1 Lab Data

WBC 4.6 NE LY
MO EO BA META

MYEL 2%

NRBC 2/100 WBC

hypersegmented Neutrophils
A few noted

29% 60%

2% 2%

2% 3%

HGB

MCV

RDW

PLT

68

120

24.2

124

Hematology Case # 1 Questions

Interpret the laboratory and morphologic findings? List 4 possible underlying diseases? What additional tests would you do?

Hematology Case # 1 Question 1

Interpret the laboratory and morphologic findings?
Macrocytic anemia with hypersegmented neutrophils, nucleated RBC, borderline neutropenia and stomatocytosis

List 4 possible underlying diseases?

alcohol intake. liver disease abnormal DNA synthesis (megaloblastic) due to B12 or folate deficiency Drugs such as methotrexate Hypothyroidism Myelodysplastic syndrome

Hematology Case # 1 What additional tests would you do?

Serum B12 Serum and red cell Folic acid

Liver Enzymes
Gamma GT ALT

TSH Bone Marrow

Hematology Case # 2
History
21 year old female who is a University student noted over the past week increasing fatigue, sore throat, headaches, and fever.

Physical Exam
She has erythematous throat and tonsils, Swollen cervical lymph nodes and hepatosplenomegaly

Hematology Case # 2 CBC with microscopic differential

Diff % 24

RBC HGB MCV RDW PLT WBC

5.25 x 1012/L 154 g/L 87.9 fL 12.2 150 x 109/L 11.9 x 109/L

Neutrophils

Lymphocytes
Monocytes Eosinophils Basophils

71
2 3 0

Hematology Case # 2 Questions

What morphologic alterations are seen in this blood smear field? What is the absolute lymphocyte count? What is the differential diagnosis? What other tests would you order?

Hematology Case # 2 Questions

What morphologic alterations are seen in this blood smear field?
Atypical lymphocytes

What is the absolute lymphocyte count?

8.4 x 109/L

What is the differential diagnosis?

viral infections
Infectious mononucleosis, CMV

Pertussis Toxoplasmosis

What other tests would you order?

Monospot test Serology for toxoplasma Serology or molecular for CMV

Hematology Case # 3
A 15-year-old girl complained of fatigue and loss of stamina. Her appetite was poor. Her monthly menstrual flow was heavy. Here CBC was as follows:

Hemoglobin MCV platelet WBC

80 g/L 65 fl 400 7 x 109/L

Case 3 CBC

Neutrophils
Lymphocytes

73%
24%

Case 3 questions
What is your diagnosis? List 4 possible underlying disease? What additional tests would you do? Explain the platelet count?

Case 3 questions
What is your diagnosis?
Microcytic hypochromic anemia

List 4 possible underlying disease?

(Fe deficiency) thalassemia anemia of chronic disease Sideroblastic anemia Pb toxicity

Case 3 questions
What additional tests would you do? Serum Ferritin Serum Iron, TIBC Hemoglobin Electrophoresis Bone marrow examination Lead level Explain the platelet count?
Typically seen in patients who are actively bleeding Increased in erythropoietin levels Bone marrow hyperplasia

Hematology Case # 4
While examining your own blood you find:
WBC 9 x 109 /L
Segmented neuts 30% bands 5% Eos 7% Basos 3% Monos 5% Lymphs 50%

Hematology Case # 4 Questions

Is this normal? Do you have too few neutrophils? Too many lymphocytes, eosinophils and basophils?

Hematology Case # 4 Questions

Is this normal?
Yes

Do you have too few neutrophils? (< 1.5 X 109/L)

2.7 x 109 /L

Too many lymphocytes? (> 4.0 X 109/L)

4.5 x 109 /L

eosinophils (> 0.35 X 109/L)

0.63 x 109 /L

Basophils (> 0.2 X 109/L)

0.27x 109 /L

Hematology Case # 5
49 year old male patient presented with fatigue. There was splenomegaly present CBC WBC 30. Hgb 120 and plt 400

Diff Segmented Neut Band

Hematology Case # 5 Diff

% 33 15

Metamylocyte Meylocyte Promyelocyte Blast Baso Eos Mono Lymph total

6 8 3 1 4 7 1 22 100

Case 5 Questions
What is the differential diagnosis?
Reactive
infection, inflammation, necrosis, physical agents, emotional stimuli, drugs, toxins, other neoplasia, metabolic, hormonal, and endocrine disturbances,

Neoplastic
Chronic myeloproliferative disorders
Chronic myeloid leukemia Essential thrombocythemia Chronic idiopathic myelofibrosis Polycythemia Vera

List 3 key diagnostic tests

Repeat CBC Bone Marrow examination Molecular for BCR/ABL Cytogenetic Study

Case 5 Questions cont

What is the Prognosis?
This a slowly progressive disease Median survival 5-7 years

List 2 treatment options

Targeted therapy tyrosine kinase inhibitors such as Imatinib Bone marrow transplant

Hematology Case # 6
Your second patient is a 37-year-old man complained of weakness. He is pale and gave a history of petechiae and hematuria. He is tired.

Hematology Case # 6 CBC

Hgb 70 g/L, WBC 2.2 x109/L, Plt 30 x109/L
Diff % Neut 23, Lymph 70 Mono 3 Eos 3 Baso 1 The PB smear showed normocytic/normochromic RBCs.

Hematology Case # 6 Questions

Calculate the absolute neutrophil count.
_______________ x 109/L

What is your diagnosis?

A. aplastic anemia B. drug induced neutropenia

C. accelerated destruction of neutrophils

Hematology Case # 6 Questions

Calculate the absolute neutrophil count.
0.5 x 109/L

What is your diagnosis?

A. aplastic anemia

Normal reference ranges

WBC HGB HGB RBC RBC MCV RDW PLT 109/L g/L g/L 1012/L 1012/L fL % 109/L (4.5 11.0) (120 - 160) (140 - 180) (3.8 5.8) (4.5 6.5) (80.0 97.0) (11.5 14.5) (150 - 350) Female male Female male