White Blood Cell and Platelet Disorders - Case Study Example

BIO3107 Haematology 2. Assignment 2. Case studies – White blood cell and platelet disorders Case 1: J.A.M, a 3-week-old febrile premature infant (31 weeks gestation). Full blood count results. Parameter Result Reference range Haemoglobin 104 g/L 102-130 g/L Red blood cell count 2.98 x 1012/L 2.98-3.94 x 1012/L Haematocrit 0.30 0.30-0.38 Mean cell volume 98 fL 94-98 fL Mean cell haemoglobin 34.9 pg 29-33.8 pg MCHC 353 g/L 310-360 g/L White cell count 28.3 x 109/L 6.4-12.1 x 109/L Platelet count 83 x 109/L 270-645 x 109/L 1. Which of the above results is a critically abnormal result? (0.5 marks) The decreased platelet count The increased white blood cell count 2. What action should you take immediately with respect to this critical result? (1 mark) Administer prophylactic platelet transfusion using higher thresholds for the febrile and septic patient. Collect samples for a full sepsis evaluation. In addition to the complete blood count, perform blood culture, urine culture, stool culture and CSF (cerebral spinal fluid) analysis. Immediately administer empiric antibiotics after collecting the cultures. Typical organisms that cause infection in the preterm infant are targeted by the antibiotics ampicillin and gentamycin or ampicillin and cefotaxime Blood film. 3. Describe the RBC morphology in baby J.A.M’s blood film. (0.5 marks) Poikilocytosis, observed as echinocytes (burr cells) in the smear. 4. What is the most likely cause of this RBC morphology? (0.5 marks) Echinocytes are common in the red blood cell of preterm infants because of the RBC’s small surface area. There is an inconsistent range of osmotic resistance in infants which affects the swelling capacity of the RBC as they move through narrow capillaries resulting in deformed red cell shapes. 5. Describe the leucocyte morphology (1.5 marks) Myeloid band formation. Nucleus twisted to form band-like C and U shapes. Vacuolization observed by clear area in the cytoplasm of the leukocytes. 6. What is the most likely cause of this leucocyte morphology and the baby’s symptoms? (1 mark) Infection. Increased number of neutrophilic bands and vacuolated neutrophile are a sign of infection. The infant is also febrile, which is a symptom in response to infection. Case 2: H.M.M a 23-year-old man presented to his GP complaining of lethargy and bleeding gums. The doctor noted that H.M.M was pale, had numerous bruises on his limbs and a fine rash on his torso. Full blood count results Parameter Result Reference range Haemoglobin 95 g/L 130-180 g/L Red blood cell count 2.92 x 1012/L 4.50-6.50 x 1012/L Haematocrit 0.271 0.40-0.54 Mean cell volume 92.8 fL 80-100 fL Mean cell haemoglobin 32.5 pg 26.5-33.0 pg MCHC 351 g/L 310-360 g/L Reticulocyte count 1.26 x 109/L 20-80 x 109/L White cell count 3.2 x 109/L 3.5-11.0 x 109/L Platelet count 51 x 109/L 150-400 x 109/L Blood film 1. Describe the morphology of the cells in the top corners of the field. (1 mark) Upper left and right atypical white cells with scant cytoplasmic granules Upper right nucleus is dense in colour with almost invisible nucleoli. Poikilocytosis of RBCs with stomatocytes and spherocystes visible. Polychromasia with blue staining cells. 2. Describe the morphology of the cell in the bottom corner of the film (1 mark) Left shift of nucleus in the leukocyte. Rod shaped inclusions (Auer bodies) in cytoplasm. 3. What is your provisional diagnosis based on the clinical presentation, the FBC results and the WBC morphology? (1 mark) Acute myeloid leukemia (AML). The WBC morphology is typical to patients with AML. Lethargy, paleness, and rash in the torso are common to most AML subtypes. The problem of bleeding gums and bruising in H.M.M results from the low platelet count that results into failure to stop bleeding. 4. What further tests should be performed immediately on this patient and why? (2 marks) Physical examination and patient history assessment, to check for other signs of disease such as lumps, and identify patient’s habits, past illnesses and possible therapies that may be significant to the current condition. Bone marrow aspiration; to determine whether myeloid lineage is in the blood or bone marrow Bone marrow biopsy; to determine nature and stage of malignancy. Cytogenetic analysis or Fluorescence in situ hybridization stain to identify changes in the chromosomes Immunophenotyping, to identify cells based on the types of markers that differentiate them from normal cells. Case 3. J.W.S a 2-year-old child admitted to paediatric surgical unit for corrective facial surgery. Full blood count results Parameter Result Reference range Haemoglobin 115 g/L 104-132 g/L Red blood cell count 5.35 x 1012/L 3.88-5.13 x 1012/L Haematocrit 0.367 0.30-0.38 Mean cell volume 68.6 fL 70-83 fL Mean cell haemoglobin 21.5 pg 23.1-29.4 pg MCHC 313 g/L 310-360 g/L White cell count 10.9 x 109/L 5.4-13.6 x 109/L Platelet count 133 x 109/L 205-553 x 109/L Mean platelet volume (MPV) 13.6 fL 7.4-11.5 fL Platelet distribution width (PDW) 17.2 fL 12.0-15.6 fL 1. What do the MPV and PDW tell you about the morphology of the platelets in this case? (1 mark) The higher mean platelet volume reveals that the platelets are large in size. Large platelets are also young, a sign that they are being rapidly produced from the bone marrow to the circulation in a rapid pace in the moment of the test. The larger platelet distribution shows that the platelets are varied in size. 2. Describe the RBC morphology in J.W.S’s blood film. (1 mark) Microcytic cells, showing smaller than normal RBCs. Hypochromia, seen by pale colour RBCs. 3. Describe the morphology of the neutrophils in J.W.S’s blood film. (1 mark) Pale blue cytoplasmic inclusions (Dohle bodies) on periphery of the neutrophilis’ cytoplasm. Neutrophilis with Segmented and band nuclei. Toxic granulation. 4. In what other conditions is this morphological feature seen? (0.5 mark) Infections of inflammatory diseases, Thermal injury from burns, Trauma, Myeloproliferative syndromes, May-Hegglin anomaly. 5. What is the most likely diagnosis in this case (1 mark) May-Hegglin Anomaly Characterised by macrothrombocytopenia and Dohle leukocyte inclusions. 6. Assuming your diagnosis is correct, what are the implications for J.W.S’s impending surgery? (0.5 mark) The anomaly will obscure a surgery that would have otherwise been less-complicated if it were not for the condition. May-Hegglin anomaly is associated with thrombocytopenia which may result in severe or recurrent bleeding after the surgery and may lead to a lower mean cell haemoglobin, indicative of microcytic anaemia. Case 4 L.M.B, an 82 year old man. Routine FBC prior to eye surgery. Full blood count results Parameter Result Reference range Haemoglobin 97 g/L 130-180 g/L Red blood cell count 3.2 x 1012/L 4.50-6.50 x 1012/L Haematocrit 0.26 0.40-0.54 Mean cell volume 82 80-100 fL Mean cell haemoglobin 30.3 26.5-33.0 pg MCHC 373 310-360 g/L Reticulocyte count 210 x 109/L 20-80 x 109/L White blood cell count 88.2 x 109/L 3.5-11.0 x 109/L Platelet count 140 x 109/L 150-400 x 109/L 1. What does the reticulocyte count indicate about the cause of L.M.B’s low haemoglobin? (0.5 mark) The high reticulocyte count shows that there is destruction of red blood cells, hence the bone marrow is continually producing and releasing premature RBCs to compensate for the destructed cells. The destruction is more rapid than the RBC release hence the lower haemoglobin and higher reticulocyte count. 2. Describe the RBC morphology in B.C.S’s blood film. (1 mark) Polychromasia, indicative of some cells being younger (recently released from bone marrow) and larger than others. 3. What pathological process is suggested by the RBC morphology (1 mark) Dyserythropoiesis, which indicates the process of RBC regeneration because of the bone marrow’s failing ability to manufacture and release adequate red cells in the circulation. 4. Which RBC feature accounts for L.M.B’s elevated MCHC? (0.5) Haemoglobin. An increase or decrease of haemoglobin directly correlates with the increase/decrease of MCHC. 5. Describe the WBC morphology in L.M.B’s blood film. (1 mark) Presence of smudge cells without cytoplasm. Disintegrating nucleus. Lymphoblasts as observed by scanty blue cytoplasm surrounding the nucleus. Granules not visible. Open nucleoli in smudge cells is a sign on immature cells. 6. What is the most likely diagnosis based on the FBC results and the blood film morphology? (1 mark) Chronic lymphocytic leukaemia Characterised by elevated WBC, elevated reticulocytes, polychromasia and smudge cells in the leukocyte smear. End of assignment 2. Reference: Butkiewicz, AM, Kemona H, Dymicka-Piekarska V, Matowicka-Karna J, Radziwon P, Lipska A, 2006, ‘Platelet count, mean platelet volume and thrombopoietic indices in healthy women and men. Thrombosis Res, 118:199- Read More