hematology cases

Hematology Case # 1Hematology Case # 1

History of Present Illness History of Present Illness – The patient was a 47-year-old white The patient was a 47-year-old white

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

Hematology Case # 1Lab Data

WBC NE LY MO EO BA META MYEL NRBChypersegmented

Neutrophils

4.6 29% 60% 2% 2% 2% 3% 2% 2/100WBC

A few noted

HGB MCV RDW PLT

68 120 24.2 124

Hematology Case # 1 Hematology Case # 1 QuestionsQuestions

Interpret the laboratory and Interpret the laboratory and morphologic findings?morphologic findings?

List 4 possible underlying diseases?List 4 possible underlying diseases?

What additional tests would you do?What additional tests would you do?

Hematology Case # 1 Hematology Case # 1 Question 1Question 1

Interpret the laboratory and Interpret the laboratory and morphologic findings?morphologic findings?– Macrocytic anemia with hypersegmented Macrocytic anemia with hypersegmented

neutrophils, nucleated RBC, borderline neutrophils, nucleated RBC, borderline neutropenia and stomatocytosisneutropenia and stomatocytosis

List 4 possible underlying List 4 possible underlying diseases?diseases?

alcohol intake. alcohol intake. liver diseaseliver diseaseabnormal DNA synthesis abnormal DNA synthesis (megaloblastic) due to B12 or folate (megaloblastic) due to B12 or folate deficiencydeficiencyDrugs such as methotrexateDrugs such as methotrexateHypothyroidismHypothyroidismMyelodysplastic syndromeMyelodysplastic syndrome

Hematology Case # 1 Hematology Case # 1 What additional tests would you What additional tests would you do?do?

Serum B12 Serum B12 Serum and red cell Folic acidSerum and red cell Folic acid

Liver EnzymesLiver Enzymes– Gamma GTGamma GT– ALTALT

TSHTSHBone MarrowBone Marrow

Hematology Case # 2Hematology Case # 2

HistoryHistory– 21 year old female who is a University 21 year old female who is a University

student noted over the past week student noted over the past week increasing fatigue, sore throat, increasing fatigue, sore throat, headaches, and fever. headaches, and fever.

Physical ExamPhysical Exam– She has erythematous throat and She has erythematous throat and

tonsils, Swollen cervical lymph nodes tonsils, Swollen cervical lymph nodes and hepatosplenomegalyand hepatosplenomegaly

Hematology Case # 2 CBC with microscopic differential

• 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

Diff %

Neutrophils

24

Lymphocytes

71

Monocytes 2

Eosinophils 3

Basophils 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 # 3Hematology Case # 3

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

Case 3 CBCCase 3 CBCHemoglobin 80 g/L

MCV 65 fl

platelet 400

WBC 7 x 109/L

Neutrophils

73%

Lymphocytes

24%

Case 3 questionsCase 3 questions

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

Case 3 questionsCase 3 questionsWhat is your diagnosis?– Microcytic hypochromic anemiaList 4 possible underlying disease?– (Fe deficiency) (Fe deficiency) – thalassemiathalassemia– anemia of chronic diseaseanemia of chronic disease– Sideroblastic anemiaSideroblastic anemia– Pb toxicityPb toxicity

Case 3 questionsCase 3 questionsWhat additional tests would you do?– SerumSerum FerritinFerritin– Serum Iron, TIBCSerum Iron, TIBC– Hemoglobin ElectrophoresisHemoglobin Electrophoresis– Bone marrow examinationBone marrow examination– Lead levelLead levelExplain the platelet count?– Typically seen in patients who are actively

bleeding– Increased in erythropoietin levels– Bone marrow hyperplasia

Hematology Case # 4Hematology Case # 4

While examining your While examining your own blood you find:own blood you find:– WBC 9 x 10WBC 9 x 1099 /L /L

Segmented neuts Segmented neuts 30%30%

bands bands 5% 5%

Eos Eos 7% 7%

Basos Basos 3%3%

Monos Monos 5%5%

Lymphs Lymphs 50%50%

Hematology Case # 4 Hematology Case # 4 QuestionsQuestions

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

Hematology Case # 4 Hematology Case # 4 QuestionsQuestions

Is this normal? – Yes

Do you have too few neutrophils? (< 1.5 X 10(< 1.5 X 1099/L) /L) – 2.7 x 109 /L

Too many lymphocytes? (> 4.0 X 10(> 4.0 X 1099/L) /L) – 4.5 x 109 /L

eosinophils (> 0.35 X 10(> 0.35 X 1099/L) /L) – 0.63 x 109 /L

Basophils (> 0.2 X 10(> 0.2 X 1099/L) /L) – 0.27x 109 /L

Hematology Case # 5Hematology Case # 549 year old male patient presented with 49 year old male patient presented with fatigue. There was splenomegaly presentfatigue. There was splenomegaly present

CBC WBC 30. Hgb 120 and plt 400CBC WBC 30. Hgb 120 and plt 400

Hematology Case # 5Hematology Case # 5DiffDiff

Diff %

Segmented Neut 33

Band 15

Metamylocyte 6

Meylocyte 8

Promyelocyte 3

Blast 1

Baso 4

Eos 7

Mono 1

Lymph 22

total 100

Case 5 QuestionsCase 5 QuestionsWhat is the differential diagnosis?– Reactive

infection, inflammation, necrosis, physical agents, emotional stimuli, drugs, infection, inflammation, necrosis, physical agents, emotional stimuli, drugs, toxins, other neoplasia, metabolic, hormonal, and endocrine disturbances,toxins, other neoplasia, metabolic, hormonal, and endocrine disturbances,

– NeoplasticChronic myeloproliferative disorders Chronic myeloproliferative disorders

– Chronic myeloid leukemiaChronic myeloid leukemia– Essential thrombocythemia– Chronic idiopathic myelofibrosis– Polycythemia VeraPolycythemia Vera

List 3 key diagnostic tests– Repeat CBC– Bone Marrow examination– Molecular for BCR/ABL– Cytogenetic Study

Case 5 Questions contCase 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 Targeted therapy tyrosine kinase inhibitors

such as Imatinibsuch as Imatinib– Bone marrow transplantBone marrow transplant

Hematology Case # 6Hematology Case # 6

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

Hematology Case # 6 CBCHematology Case # 6 CBC

Hgb 70 g/L, WBC 2.2 x10Hgb 70 g/L, WBC 2.2 x1099/L, Plt 30 /L, Plt 30 x10x1099/L/L– Diff Diff %%– Neut Neut 23, 23, – LymphLymph 7070– MonoMono 33– EosEos 33– BasoBaso 11– The PB smear showed The PB smear showed

normocytic/normochromic RBCs.normocytic/normochromic RBCs.

Hematology Case # 6 Hematology Case # 6 QuestionsQuestions

Calculate the absolute neutrophil Calculate the absolute neutrophil count.count.– _______________ x 109/L_______________ x 109/L

What is your diagnosis?What is your diagnosis?– A. aplastic anemiaA. aplastic anemia

– B. drug induced neutropeniaB. drug induced neutropenia

– C. accelerated destruction of neutrophilsC. accelerated destruction of neutrophils

Hematology Case # 6 Hematology Case # 6 QuestionsQuestions

Calculate the absolute neutrophil Calculate the absolute neutrophil count.count.– 0.5 x 100.5 x 1099/L/L

What is your diagnosis?What is your diagnosis?– A. aplastic anemiaA. aplastic anemia

Normal reference rangesNormal reference ranges

WBCWBC 101099/L/L(4.5 – 11.0)(4.5 – 11.0)HGBHGB g/Lg/L (120 - 160)(120 - 160) FemaleFemaleHGBHGB g/Lg/L (140 - 180)(140 - 180) male male RBCRBC 10101212/L/L (3.8 – 5.8)(3.8 – 5.8)FemaleFemaleRBCRBC 10101212/L/L (4.5 – 6.5) (4.5 – 6.5) malemaleMCVMCV fLfL (80.0 – 97.0)(80.0 – 97.0)RDWRDW %% (11.5 – 14.5)(11.5 – 14.5)PLTPLT 101099/L/L (150 - 350) (150 - 350)