Morphology Unit – WBC Cases
For these cases, it is assumed that you
have taken advantage of the Rotation I
Reviews to recall the information you
mastered during Rotation I. Remember to
make use of the Rotation I WBC worksheet,
quizzes and Flow Cytometry exercise.
CLS417 - CLINICAL HEMATOLOGY II
Linda Sykora, MT(ASCP)SH
Rotation II Morphology Unit
WBC Cases
Before proceeding, you will need to have
your Rotation II Morphology Unit objectives
and handouts available.
Pictures Copyright © University of Nebraska 2008
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For the WBC disorders, your first steps should
include evaluation of the WBC count and differential
(% and absolute #s) to determine the predominant
cell type. The presence or absence of anemia or
thrombocytopenia should also be noted.
Morphology Unit – WBC Cases
The WBC cases will cover much (but not
all) of the material you are responsible for.
Use your objectives as a guide to identify
material in italics that is new for Rotation II.
Patient age and WBC morphologic changes (e.g.,
toxic neutrophils or reactive lymphocytes) can provide
clues to a reactive versus a malignant cause.
For new information, you will be referred to
pages in the SL manual, handouts in the
Rotation II Morphology unit and/or your
McKenzie text.
Note: Throughout the case slides, click on
would like to view the previous slide.
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if you
Most benign disorders can be distinguished from
malignant disorders without doing a bone marrow;
a marrow exam is generally required to establish a
definitive diagnosis of malignancy.
Refer to WBC classification sheet on SL pg 178.
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Which of the following blood findings indicate the need for
a bone marrow evaluation?
a. Suspected blast cells or lymphoma cells are seen
b. Significant neutropenia is present
c. Unexplained pancytopenia exists
d. Dysplastic cells that exhibit features of abnormal
growth, i.e. dyspoiesis, are present
e. All of the above
Refer to Rot II Morph unit Bone Marrow & Terms Handout
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The cells shown may be seen in normal bone marrow.
1. What are the cells (A) that make the bone and resemble
plasma cells but are much bigger?
2. What is the multi-lobed cell (B) that produces platelets?
3. What is the multi-nucleated cell (C) that removes bone
and resembles cell (B)?
See normal bone marrow cells on Morph unit Terms Handout.
Marrow 100x
Marrow 100x
Marrow 100x
A
B
C
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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The cell (A) is a normal macrophage/histiocyte that is
present in the bone marrow, spleen, liver and other tissues.
1. The cell (B) is an abnormal macrophage full of the
unmetabolized lipid, glucocerebroside. It is a:
2. The cell (C) is an abnormal macrophage full of the
unmetabolized lipid, sphingomyelin. It is a:
See cells present in lipid storage disorders on Terms Handout.
Marrow 100x
A
Marrow 100x
B
Case A
A 4 year old girl is brought to the ER
due to fever. Lab data:
WBC 19.2 K/uL; Hgb 12.0 g/dL;
PLT 200 K/uL; Differential results:
58 segs-25 bands-10 lymphs-7 monos
Appearance of her neutrophils is shown.
Marrow 100x
1. Which of the following best describes her results?
a. regenerative left shift
b. degenerative left shift
c. neutrophilic leukemoid reaction
d. leukoerythroblastic reaction
C
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Case B
Case A
2. How did you rule out the other possibilities (b,c,d)?
3. Her results are indicative of:
a. viral infection
b. acute lymphocytic leukemia
c. bacterial infection
d. normal findings
This 2 year old male has had multiple infections since age of 1
year. Infections have included pneumonias, skin infections and
abscesses of the lung due primarily to staphylococci. His blood
smear shows white blood cells that are normal in appearance
however his red cells are acanthocytes.
1. What is his most likely disorder?
a. Pelger-Huet anomaly
b. May-Hegglin anomaly
c. Alder-Reilly anomaly
d. Chediak-Higashi anomaly
e. Chronic Granulomatous disease
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The LAP stain detects the activity of the enzyme alkaline
phosphatase in the cytoplasm of neutrophils (2o granules).
The amount of red precipitate in seg & band neutrophils is
graded 0-4+ to obtain a score. A normal score is 1313-130.
Case C
A 50 year old male with a ‘red nose’ and chest pain has
the following lab data:
WBC 20.0 K/uL; Hgb 22.0 g/dL; PLT 995 K/uL
Diff: 52 segs-15 bands-12 lymphs-7 monos-4 basos; 1 NRBC
LAP stain
1. The LAP stain shown has a high
score (185). This is consistent
with all of the following except:
(4+)
a. Chronic myelocytic leukemia
b. Severe bacterial infection
c. Polycythemia vera
d. Idiopathic myelofibrosis
See LAP on SL pg 191
LAP 144; Erythropoietin (EPO) level low
1. His results are most consistent with: See SL page 203 &
a. aplastic anemia
chart on SL page 205
b. primary polycythemia vera
c. idiopathic/essential thrombocythemia
d. chronic myelogenous leukemia
e. polycythemia secondary to hypoxia
f. pseudo polycythemia
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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Case D
The following results were obtained on a 75 year old male
with severe abdominal pain:
Case C
2. How did you rule out the other possibilities (a,c,d,e,f)?
3. What RBC mass and plasma volume is typical for this
type of patient?
4. What bone marrow M:E ratio do you expect?
5. What is the usual treatment?
WBC 5.0 K/uL; Hgb 8.0 g/dL; PLT 99 K/uL
Diff: 16 segs-22 bands-28 lymphs-16 monos-1 eos-1 baso4 metas-8 myelos-4 promyelos; 30 NRBCs/diff
Teardrop red cells were noted on the blood smear (shown). A
bone marrow aspirate was a “dry tap”. LAP score was 142;
Philadelphia chromosome negative.
1. These results are consistent with:
a. primary polycythemia rubra vera
b. idiopathic/primary thrombocythemia
c. chronic myelocytic leukemia
d. myelofibrosis with myeloid metaplasia
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Case E
A 60 year old female whose favorite song is “Don’t Worry,
Be Happy”, has a history of recurrent GI bleeds. Lab data:
Case D
2. How did you rule out the other possibilities (a,b,c)?
3. What is seen on a leukoerythroblastic differential?
4. What does myeloid metaplasia mean? What was the
likely cause of this patient’s abdominal pain?
WBC 8.0 K/uL; Hgb 8.0 g/dL; PLT 1,500,000/uL
Diff: 70 segs-10 bands-18 lymphs-2 monos
Her blood smear is shown.
1. Her results are consistent with:
a. primary polycythemia vera
b. idiopathic myelofibrosis
c. essential thrombocythemia
d. reactive thrombocytosis
2. What marrow cell is increased?
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Case G
A 61 year old farmer complained of generalized bone pain
to his local medical doctor. He was noted to have
splenomegaly during his physical exam. Lab data:
Case F
A 55 year old male who walks his dog everyday, comes to
the ER with a temperature of 1030 F. His lab findings:
WBC 74.8 K/uL; Hgb 11.5 g/dL; PLT 305 K/uL; LAP score 210
Diff: 44 segs-40 bands-1 lymph-3 monos-0 eos-0 basos5 metas-7 myelos. His WBC abnormalities are shown.
WBC 145.8 K/uL; Hgb 10.9 g/dL; PLT 344 K/uL; LAP score 1
Diff: 56 segs-15 bands-4 lymphs-1 monos-2 eos-5 basos4 metas-12 myelos-1 promyelo. An occasional blast was noted.
Testing revealed a 9;22 translocation and BCR/ABL mutation.
1. What is his most likely
disorder and its cause?
2. How did you rule out CML?
1. What is his most likely disorder? Support your answer.
2. What % of cases have the Philadelphia chromosome and/or
BCR/ABL gene mutation?
3. What would you expect in his bone marrow?
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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Case H
A 43 year old female was diagnosed with CML two years
ago when a WBC of 121.1 K/uL was discovered during
a routine physical. Her response to Gleevec has been poor.
She now has the following lab data:
Case I
This 53 year year old male had noticed the onset of easy
fatigability and bruising. He saw his doctor when he
developed a boil in the perianal area. His blood smear
and bone marrow are shown. Lab data: Bone Marrow 100x
WBC 65.8 K/uL; Hgb 7.5 g/dL; PLT 34 K/uL
Her diff has 50% blasts (shown); genetic tests
revealed multiple chromosome abnormalities.
WBC 78.0 K/uL; Hgb 7.3 g/dL; PLT 59 K/uL
1. What is the most likely
diagnosis?
2. What further testing would
you suggest?
1. What has occurred? What’s her prognosis?
2. Under what circumstances might the LAP score in a CML
patient be greater than 13?
Blood
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3. What peroxidase, SBB, and PAS stain results do you
expect for the blast cells in Case I? How will Auer rods
stain?
4. Which of the following marker panels do you expect will be
positive in this case?
a. CD13, CD33, CD34
b. CD2, CD3, CD4
c. CD10, CD19, CD20
5. Are the expected stain & marker results always obtained?
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Case J
A 48 year female with a sudden onset of weakness and
fatigue went to her doctor. Her lab data revealed:
WBC 43.6 K/uL; Hgb 5.3 g/dL;
PLT 24 K/uL
Diff: 1 seg-11 lymphs-88 blasts
The blasts were noted to have some
monocytic features and immature
monocytes were present (shown).
The bone marrow showed similar cells.
1. What is the most likely diagnosis?
2. What further testing would you suggest that could determine
the leukemia subtype?
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The blasts in Case J were peroxidase and SBB positive
and expressed CD13 and CD33. The cells were also positive
for CD14, a monocytic marker. The blast cells showed
positivity for both the specific and nonspecific esterase stains.
See SL pg 190 and Morph unit FAB Leukemia Chart handout
and/or McKenzie chapter 24.
3. Based on these results, which type of acute leukemia does
this lady most likely have? Support your answer.
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Case K
A 24 year old woman, an American Idol ‘wanna-be’, was seen
due to weakness and recurrent nosebleeds. Lab findings
revealed anemia and severe thrombocytopenia (PLT 18 K/uL).
Her WBC was normal but her diff had 2 segs-40 blasts and
58 blast-like cells with intense granulation. Some cells had
bundles of ‘bodies’ in the cytoplasm.
STAT coag results showed prolonged PT/APTT tests, a low
fibrinogen level, and a positive/increased Dimer test.
1. Which type of acute leukemia do you suspect?
2. What do you think the ‘bodies’ are?
3. What is the significance of her coagulation results?
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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Case L
The bone marrow performed on the patient in Case K is
Bone Marrow 100x
shown. Additional testing
included cytochemical stains,
flow cytometry and cytogenetics.
4. What results do you expect
for the peroxidase, SBB and
specific esterase stains?
5. What genetic abnormality
was likely detected?
An 80 year old man with abnormal blood and bone marrow
findings is suspected to have acute erythroleukemia (EL), M6.
His bone marrow contains 40% myeloblasts and numerous
giant RBC precursors similar to those seen in megaloblastic
anemia, however his folate and B12 levels are normal.
1. What term is used to describe giant RBC precursors that
mimic those seen in megaloblastic anemia?
See Morph unit Terms Handout.
2. What cytochemical stain is used to differentiate malignant
erythroid cells from normal/benign red cell precursors?
See SL pg 190 and Morph unit FAB Leukemia Chart handout.
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Case M
The giant, multinucleated RBC precursors from the
patient in Case L stained PAS positive (on right).
This is consistent with malignant red cells and a
diagnosis of EL, FAB type M6.
A 70 year old female with “possible leukemia” is transferred to
your hospital for evaluation. A CBC reveals the following:
WBC 2.4 K/uL; Hgb 9.0 g/dL; MCV 110.5 fL; RDW 27.4%;
PLT 80 K/uL; Diff: 68 segs-6 bands-18 lymphs-3 monos-5 blasts
Her folate and B12 levels are normal. A bone marrow exam
reveals 75% cellularity and 24% blasts, a few with Auer rods.
Erythrocytic, granulocytic and megakaryocytic precursors
exhibit features of abnormal growth (dysplasia). Monocytic cells
are normal in number. See Morph unit MDS & Terms Handouts
PAS (+)
Bone Marrow 100x
Bone Marrow 100x
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PAS stain Bone Marrow
1. According to the FAB classification, this patient likely has:
a.
b.
c.
d.
AML, M2
Refractory Anemia with Excess Blasts (RAEB)
RAEB in transformation (RAEB-T)
ALL, L2
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Case M Features of abnormal growth in MDS
2. You suspect this diagnosis for Case M because…………
3. Does this patient exhibit one or more blood cytopenias?
4. Name at least five signs of abnormal growth that were most
likely present in the bone marrow (or blood) of this patient.
5. According to the WHO classification, this patient has:
Normal RBC precursors
Megaloblastoid
Megaloblastoid RBC precursors
Bone Marrow 100x
Bone Marrow 100x
Multinucleated RBC
Monocytes
Dysplastic NucRBCs
See next slides to view features of abnormal growth.29
CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
Dimorphism, macromacro-ovalocytes
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Blood
Blood
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Case M Features of abnormal growth in MDS
Case N
A 6 year old boy had a 2 to 3 week history of fever at night
and cervical adenopathy. Physical exam showed a
generalized lymphadenopathy. His lab data:
Hypogranular
neutrophils
Blast
Blast
Neutrophil,
Neutrophil,
normal granulation
Blood
WBC 20.7 K/uL; Hgb 10.9 g/dL; PLT 123 K/uL
Diff results: 1 segs-17 lymphs-1 monos-81 blasts
Hypogranular and hyposegmented
(aka pelgeroid
pelgeroid)) neutrophil
1. What do you suspect?
2. What is his absolute neutrophil count? Should you be
concerned that he has a high risk of infection?
3. What is the next step for this patient?
Blood
Blood
Blood
Lymph
Blast
Dysplastic (bizarre) platelets
Micromegakaryocyte
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The bone marrow obtained on the patient in Case N was
hypercellular with 80% blasts that were fairly small and
homogeneous. Blasts were not detected in his CSF. His
blasts were peroxidase/SBB negative and PAS positive.
Immunophenotyping showed positivity for CD10, CD19,
and CD34; cells were negative for CD2/3. See Morph unit
FAB Leukemia Chart handout and/or McKenzie text.
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Case O
This 72 year old male was discovered to have an elevated
WBC count 4 years ago. He has never received therapy
for his disorder. Physical examination showed no palpable
lymphadenopathy. Lab data:
WBC 90.7 K/uL; Hgb 13.9 g/dL
PLT 223 K/uL
Diff:10 segs-89 lymphs-1 mono
His blood smear is shown.
4. These results are most consistent with:
a. Precursor-B ALL, CALLA type
b. T cell ALL
5. Does this patient have a good prognosis?
1. What is his most likely diagnosis and why?
2. Are these usually malignant T or B cells?
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Case P
A 45 year old male presents with pancytopenia and
splenomegaly. Several ‘lymph-like’ cells with monocytic
cytoplasm are observed on his blood smear. A bone
marrow aspirate is a “dry tap”. A TRAP stain, done on
the ‘lymph-like’ cells, is shown.
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Case P
2. How did you rule out the other possibilities (a,b,d,e)?
TRAP (+)
1. This information is consistent
with a diagnosis of:
a. Hodgkin’s lymphoma
b. CMV infection
TRAP stain
c. Hairy cell leukemia
d. Chronic lymphocytic leukemia in blast crisis
e. Waldenstrom’s macroglobulinemia
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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NonNon-Hodgkin’
Hodgkin’s lymphomas (NHLs) comprise a very large
group of disorders that are constantly being reclassified.
You are responsible for selected examples.
examples Refer to SL
pg 207 and pg 8 of the Rotation II Morph unit objectives.
NHL comments:
■ Patients with NHL often have a normal CBC/diff initially,
when proliferation is still limited to the lymphoid tissues.
■ A lymphoma and a leukemia with the same malignant cell
type are the same disease,
disease they just have a different
presentation, e.g. bone marrow & blood vs lymphoid tissue.
■ Immunophenotyping is essential for determining cell
maturity (precursor or mature) and the malignant cell type;
most NHL’s are B cell type but some are T/NK cell type.
See the next slides to view the malignant cell types in
certain nonnon-Hodgkin’
Hodgkin’s lymphomas.
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Patient A has small lymphocytic lymphoma that has spread
from the tissues to bone marrow and blood (peripheralized).
SLL is the tissue counterpart of:
Patient B has peripheralized ‘mixed’ cell lymphocytic
lymphoma. These clefted lymphoid cells are called:
Patient A
Patient B
Patient C
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Patient D has peripheralized Burkitt’s lymphoma that is
associated with EBV and t(8;14). The leukemic form is called:
Patient E has mycosis fungoides, a T cell lymphoma that
involves the:
Patient E
Patient E
Patient D
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CLS 417 Clinical Hematology II Rot II
Morph Unit WBC Cases
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