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 NE LY MO EO BA META MYEL NRBC hypersegmented Neutrophils 4.6 29% 60% 2% 3% 2/100 A few noted 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 Physical Exam 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 % Neutrophils 24 Lymphocytes 71 Monocytes 2 Eosinophils 3 Basophils RBC 5.25 x 1012/L HGB 154 g/L MCV 87.9 fL RDW 12.2 PLT 150 x 109/L WBC 11.9 x 109/L

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:

Case 3 CBC Hemoglobin 80 g/L MCV 65 fl platelet 400 WBC 7 x 109/L Neutrophils 73% Lymphocytes 24% Case 3 CBC

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 Iron, TIBC 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

Hematology Case # 5 Diff Diff % Segmented Neut 33 Band 15 Metamylocyte 6 Meylocyte 8 Promyelocyte 3 Blast 1 Baso 4 Eos 7 Mono Lymph 22 total 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? List 2 treatment options 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 109/L (4.5 – 11.0) HGB g/L (120 - 160) Female HGB g/L (140 - 180) male RBC 1012/L (3.8 – 5.8) Female RBC 1012/L (4.5 – 6.5) male MCV fL (80.0 – 97.0) RDW % (11.5 – 14.5) PLT 109/L (150 - 350)