11-11-98
Case: 35 year old female
-neutropenia -lymphocytosis (relative)
-slight hypochromia
-elevated ESR
-slight thrombocytopenia (not significant)
-atypical lymphocytes (11%)
-normal morphology
-viral (right shift)- mumps, German measles
-white count-neutrophil count typically follows WBC
-neutropenia accompanies leukemia
-lymphocytosis accompanies neutropenia
Right shift – infection (viral)
-relatively low WBC’s
-relatively low neutrophils
-relatively high lymphocytes
NOT anemia- RBC count is normal with a borderline hematocrit and a normal MCV
-short term: to lower hematocrit without lowering RBC’s = guzzle water
-hemogram is negative
-high sed rate (ESR)
-consider all categories
what if a 60 year old with no improvement after 4 weeks (with an ESR = 60) consider occult neoplasm
so consider sed rate in relation to CBC
most important component is the morphology:
-if morphology is normal:
-not leukemia, marrow disease or anemia
atypical lymphocytes (usually 8% is normal) 11% is high
-have vacuoles in cytoplasm this indicates infection
-expect 30-40% for leukemia
so, Right shift, inc. ESR, not much else except sight inc. in atypical lymph’s = infection
Chief complaint is probably respiratory (easy to transmit)
-need history to know system involved (GI, CNS, etc.)
CNS- cerebritis, meningitis (bacterial is worse) often fatal in hours
Case-26 year old male with excruciating low back pain (X-rays are neg.)
-leukocytosis -neutrophilia
-lymphopenia -normal RBC’s
-normal ESR -normal platelets
-increased bands
case- moderate toxic granulation of segs
Differential = acute infection, toxicity
11-13-98
Case- 26 year old male
-infection- leukocytosis, neutrophilia, bands (left shift = bacterial)
-relative lymphopenia (due to inc. in neutrophils not dec. lymphocytes)
-RBC’s and platelets are normal (not anemia)
-if low back pain and infection:
Q- where do we localize it to ? is it spine related? – check by testing
-is it mechanical or pathological? – ex. Infection is pathological
If pathological = differential is infection (where is it?)
Patient has impaired mobility (reinforces spinal location)
If extraspinal, usually have okay mobility (it just hurts-patient reports pain-doctor elicits tenderness.
Well preserved joint spaces, good vertebrae’s. renal system is #1 source of LBP outside of the spine.
Case: suppose ESR = 90 (high)- tissue damage (cancer, serious infection)
-severe pain, insidious onset, radiographically occult.
-vertebrae has a rich sinusoidal blood supply (easy to bring infection into the spine)
-possible: paraspinal structures, neural structures, vertebral body
History: recent surgery makes infection more possible (spinal, pelvic)
-immunocompromised: diabetes, elderly, AIDS, IV drug users
toxic granulation – segs had debris due to consumption of microorganisms
Why is it radiographically negative early on? Has to reach a threshold of bone destruction
Case: 58 year old female
-leukopenia
-neutropenia
-relative lymphocytosis
-mild basophilia
-anemia
-hypochromic
-low hematocrit -1% reticulocyte (normal)
-rouleaux (protein problem)
Differential: right shift infection
-anemia (normocytic) – underproduction due to normal reticulocytes (could be a marrow neoplasm): primary leukemia,
multiple myeloma, lymphoma, or secondary from elsewhere
-Rouleaux = too much protein – multiple myeloma (back pain make worse by activity better by rest. Mimics
pathomechanical)
-low WBC makes them prone to infection ( usually due to infection)
-Multiple myeloma is myelophthisic – no abnormal morphology (no blasts). See punched out lesions in skull (moth
eaten). Associated with Ig elevation (esp. IgG). Bone scan not helpful. #1 malignancy of the skeleton. Need lab tests
to diagnose.
Case: -thrombocytopenia ( and abnormal platelets)- marked increase in monocytes – neutropenia – anemia (dec. RBC’s,
dec. hematocrit): microcytic, hypochromic
-not infection
promonocytes (immature marrow cells) – not normally seen in peripheral stream = neoplasm (probably leukemia)
if all 3 cell lines are decreased, think neoplasm ( infection only impacts white count, not RBC’s or platelets)
11-16-98
Case: leukocytosis – elevated bands – lymphocytopenia – no anemia – okay platelets
Bands with left shift = bacterial infection
Case: 20 year old female
-marked eosinophilia – Basophilia – normal RBC’s, platelets, other WBC counts (unlikely to be infection)
Differential: allergy (possible history: bee sting, high pollen count
-basophilia tend to associate with foreign protein reactions, possibly something eaten (ex. Angioneurotic edema
,Br, I)
-eosinophilia could be Hodgkins lymphoma (if older than 30), parasites
-no anemia or polycythemia
patient is wheezing, rhinitis, tearing = allergy or asthma
-pemphigris- large blisters (ex. Poison ivy)
-parasite – diarrhea
chronic allergies – often have a low level of eosinophilia
Case: 35 year old female with a dry cough for 2 months
-leukopenia
-neutropenia
-lymphocytosis
= Right shift (viral)
-slight thrombocytopenia
-slight hypochromia (patient is overhydrated so ignore idea of anemia)
-elevated ESR -atypical lymph’s (11%)
-normal morphology of RBC’s
differential: TB, mono
-atypical lymph’s and inc. ESR = busted up cells
-cough ( respiratory viral = right shift) probably upper RT infection of viral origin
-chronic may aspirate bacterial pathogens into URT and get bacterial pneumonia (due to compromised immune
system barrier at trachea) = walking pneumonia
-why MD’s used to like to prescribe antibiotics for viral infections
Left shift – bands inc. = bacterial infection
If no bands could be just inflammation (ex. RA)
Hemorrhages
Physiological – exercise leads to inc. leukocytes
-smokers
-med workers (due to constant exposure to germs)
necrosis – hypoxic tissues undergoing ischemic change
Case:45 year old female
-leukocytosis -neutropenia
-lymphocytosis -inc. bands
-slight thrombocytopenia
-no anemia
-normal RBC morphology
-atypical lymphocytes (50%)
expect a left shift due to inc. bands but see a right shift = schizoid shift
--differential: mono (right shift and atypical lymphocytes)-split shift
mono lookalike is HIV (it evolves in a similar way): fatigue, malaise, adenopathy
why acute HIV isn’t usually diagnose (because it resembles mono)
11-18-98
Review session of cases:
1.) 21 year old female
-leukopenia -neutrophilia –lymphocytosis (relative) – dec. platelets
-anemia (microcytic hypochromic) – basophilia – atypical lymph’s
-metamyelocytes, lymphoblasts
=all 3 lines are decreased
Differential: lymphoblastic (neoplasm-leukemia)
-infection – anemia (of bone marrow origin)
Clinical: malaise – history of infections – pallor (anemia) – lymphadenopathy – bleeding phenomena (purpura, etc.)
-not polycythemia
-could be aplastic anemia and marrow problem = leukemia
-morphology is key feature (infantile cells)
Leukemia presents with blast cells
2.) 24 year old female
-slight anemia (moderate microcytic hypochromic) – slight leukopenia – slight neutropenia – lymphocytosis – slight
thrombocytosis – slight anisocytosis – slight poikilocytosis – moderate # of target cells – slight polychromasia
-no bands = NO left shift
-borderline fight shift (infection)
-Anemia ( vascular category)
Differential: microcytic anemia (Fe deficiency most common, Thalassemia, sideroblastic)
Need more tests: Fe is low and TIBC is elevated = Fe deficiency ( if both were normal = thalassemia)
-target cells in body Fe def./thalassemia (don’t want to give if thalassemia- makes them sick)
3.) 82 year old male
-normal WBC – elevated RBC’s (erythrocytosis) – hyperchromic – okay platelets – normal morphology
Differential: vascular (category)
-poycythemia (probably secondary since WBC and platelets are normal ) = erythrocytosis elevated RBC’s,
hematocrit, hemoglobin
-not infection or marrow disease
Cause: COPD – congestive heart failure – chronic cardiopulmonary distress
-if relative erythrocytosis = other differential might be altitude or dehydration (due to age)
so, need to know the clinical status of the patient
4.) 57 year old male
-marked leukocytosis – numerous bands – marked lymphopenia – slight monocytosis – some basophilia – marked
thrombocytosis – marked erythrocytosis – marked hematocrit and hemoglobin – marked polychromasia – moderate
spherocytosis and microsytosis
Differential: neoplasm (category) – WBC count too high for infection (more than 40)
-Left shift but not neutrophilia (mostly immature cells – myelocytes, metamyelocytes, bands)
-Not anemia due to inc. hematocrit
-Primary polycythemia due to inc. WBC’s, and platelets
Clinical: red face – HT – embolism and thrombosis in history – splenomegaly
Metaplasia leads to dysplasia which leads to Neoplasia
-polycythemia treatment is blood letting (phlebotomy)
5.) 77 year old female
-leukopenia – normal neutrophils and lymph’s – moderate thrombocytopenia – erythrocytosis and macrocytosis –
moderate hypochromia (= anemia) – hypersegmented neutrophils – marked ovalocytes, anisocytosis and poikilosis,
macrocytosis – moderate basophilic stippling
-not immature cells
Differential: macrocytic anemia (B12, folic acid – either dec. intake, absorption or inc. utilization) elderly possibly a
bad diet (pernicious anemia = absorption)
-40% of people over 60 have diverticulosis which leads to a dec. in B12 absorption = alcoholism