Hematology Case # 1

1. 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.

2. Hematology Case # 1Lab Data

3. Hematology Case # 1 Questions • Interpret the laboratory and morphologic findings? • List 4 possible underlying diseases? • What additional tests would you do?

4. Hematology Case # 1 Question 1 • Interpret the laboratory and morphologic findings? • Macrocytic anemia with hypersegmented neutrophils, nucleated RBC, borderline neutropenia and stomatocytosis

5. 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

6. 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

7. 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

8. Hematology Case # 2CBC 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

9. 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?

10. 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

11. 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:

12. Case 3 CBC

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

14. 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

15. Case 3 questions • What additional tests would you do? • SerumFerritin • 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

16. 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%

17. Hematology Case # 4 Questions • Is this normal? • Do you have too few neutrophils? • Too many lymphocytes, eosinophils and basophils?

18. 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

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

20. Hematology Case # 5Diff

21. 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

22. 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

23. 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.

24. 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.

25. 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

26. Hematology Case # 6 Questions • Calculate the absolute neutrophil count. • 0.5 x 109/L • What is your diagnosis? • A. aplastic anemia

27. 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)