Hematopathology Lab December 12, 2013

Case 1

. Normal Peripheral Blood Smear

Q1. Describe the normal morphology of the red blood cells (RBCs) Q2. Identify and describe the white blood cells (WBCs) in the smear Q3. Identify the platelets in the smear and describe their characteristics. How many do you see in the high power field?

Q4. Describe how a peripheral blood smear is made.

Case 2

History A 45-year-old woman presents with perimenopausal menometrorrhagia. CBC: WBC 9.7x10 3 /uL Hemoglobin 7.8g/dL Hematocrit 23.5% MCV 73 femtoliters (fL) Red cell distribution width (RDW) 22.1 Platelets 187,000/uL

-RBCs are smaller than Patient’s Blood Smear Normal

Q1 Describe the morphology of the RBCs. Contrast to the normal peripheral blood smear. Q2 Correlate the findings on the peripheral smear with the CBC indices.

Q3 What is your diagnosis? Q4 What is the etiology in this patient? What are other etiologies?

Q5 What symptoms and physical exam findings may be associated with this condition? Q6 What is “Plummer Vinson Syndrome”?

Case 3

Case History A 22-year-old African-American man presents with severe pain in several joints and diffuse abdominal pain. He states he is active physically and participates in different sports several times a week. He has had no fevers or chills. Review of systems is negative for any symptoms of infection.

CBC findings: WBC 13.2x10 3 /uL Hemoglobin 7.9g/dL Hematocrit 22.8% MCV 91.4 femtoliters (fL) RDW 24.1 Platelets 481,000/uL

Peripheral Blood Smear

Q1 Describe the morphology of the RBCs. Q2 What is your diagnosis? Q3. Define “poikilocytosis” and how it is demonstrated on the smear.

Q4. What are the most common genetic mutations associated with this disease? Q5. Explain the etiology of the patient’s symptoms. Why was the absence of symptoms of infection specifically noted?

Q6 Describe the likely gross morphology of this patient’s spleen. What are the clinical implications? Q7 Define “acute chest syndrome”.

Case 4

CASE 4 History A 60 year-old man presents with mild fatigue. Further questioning reveals a vague feeling of abdominal “fullness” and more bruising of his skin. Physical examination is remarkable for splenomegaly to the level of the umbilicus.

CBC findings: WBC 75.1x10 3 /uL Hemoglobin 8.5g/dL Hematocrit 25.5% Platelets 56,000/uL MCV 88.4 femtoliters (fL) RDW 16.1 The hematology analyzer has flagged the specimen for possible immature WBC forms

- WBCs are markedly increased in number, predominantly cells of the neutrophil series. -Many mature neutrophils are seen as well as earlier forms showing a)less nuclear segmentation (bands, myelocytes) and b) prominent primary granules without secondary fine pink granulation (promyelocytes). No blasts are seen. Peripheral Blood Smear Image A

Q1 Describe the findings on the peripheral smear. Do you agree that there is an increased number of immature WBC forms in the peripheral blood? Name the cells indicated by the arrows.

Peripheral Blood Smear Image B

Q2 There was also an increased number of cells highlighted by the arrow in peripheral blood smear image B. What is the cell?

A Bone Marrow Biopsy is done A B

Normal Bone Marrow Biopsy (patient of similar age) A B

Q3 What do “A” and “B” represent? Q4 On low power, what is the most striking difference between the patient’s bone marrow and the normal bone marrow?

Bone Marrow Karyotype

Q5 What is your diagnosis? Q6 Define “leukemoid reaction”. What distinguishes leukemoid reaction from our patient’s diagnosis?

Q7 How do the history and physical examination findings relate to the diagnosis and to the CBC results?

Q8 The image is from a patient with the same disease who underwent autopsy examination. Explain the findings.

Q9 What is the clinical significance of the identified findings on the karyotype?

Case 5

At low magnification, the lymph node is surrounded by a thin capsule o Reactive Lymph Node Low Power Q1 Describe the architecture. Identify/describe the structures highlighted by arrows, circle A B

On higher magnification, germinal centers show normal spacing in between in each other Higher Power Q2 Name the structures highlighted by the asterix. What is “A”? * * A

Q3 What types of cells compose the structure highlighted by the asterix? * High Power

Q4 What size are normal lymph nodes? Q5 Are peripheral lymph nodes palpable in normal healthy individuals?

Case 6

History A 35 year-old man presents for evaluation of an enlarged non-tender cervical lymph node. The node has shown progressive enlargement over the past 4 months. The patient denies other symptoms such as fevers, night sweats, weight loss or fatigue.

Q1 Develop a differential diagnosis (using broad categories) for cervical lymphadenopathy

CBC WBC 7.2x10 3 /uL Hemoglobin 14.2g/dL Hematocrit 43.3% MCV 87.0 femtoliters (fL) RDW 14.1 Platelets 372,000/uL An excisional biopsy of a enlarged lymph node is performed.

Q2 Comment on the size of the lymph node. Describe the gross findings. Bisected lymph node

Low power Q3 Describe the histologic findings. Compare to the reactive lymph node. What is the asterix highlighting? Reactive Node *

Within the nodules, Q4 Describe the higher power findings.

Q5 Describe the high power findings. What is the arrow highlighting?

Q6 What is your diagnosis? Q7 What are other common histologic subtypes of this disease? Q8 What does the term “B Symptoms” refer to?

Case 7

History A 51 year-old man presents with fatigue, malaise and occasional low grade fevers. Physical examination reveals bilateral non-tender cervical lymphadenopathy and an enlarged inguinal lymph node.

CBC WBC 6.2x10 3 /uL Hemoglobin 11.8g/dL Hematocrit 36.1% MCV 92.0 femtoliters (fL) RDW 16.1 Platelets 180,000/uL An excisional biopsy of a cervical lymph node was performed.

Describe the low and high power. Q1 Describe the low power histologic findings. Compare to the reactive lymph node Reactive

Q2 Describe the cells within the germinal centers. Compare to the reactive lymph node. Reactive node

Q3 What is your diagnosis? Q4 What specific genetic changes are seen in this type of lymphoma?

Q5 Summarize the morphologic features which distinguish this lymphoma from a reactive lymph node (reactive follicular hyperplasia). Q6 Describe the general course/prognosis of this lymphoma. Are all patients with this lymphoma treated?

Case 8

History A 58 year-old man is seen by his primary care physician for a physical examination. Overall, he feels well. His wife is concerned about the “lumps” on his neck. Physical examination is remarkable for for non-tender cervical, axillary and inguinal lymphadenopathy. The spleen is not enlarged.

Patient has marked bilateral lymphadenopathy

Patient has marked axillary lymphadenopathy

The patient has a CBC drawn: WBC 39.6 x10 3 /uL Hemoglobin 10.5g/dL Hematocrit 30.2% MCV 86.0 fL Red cell distribution width (RDW) 16.2 Platelets 149,000/uL

Describe the peripheral Q1 Describe the findings on the peripheral blood smear. What does the cell with the asterix above it represent? *

Q2 What is your diagnosis? If a bone marrow biopsy were done, what would it show? Q3. Are the findings on the CBC and peripheral blood smear related to the patient’s lymphadenopathy?

If a lymph node biopsy were to be done on this patient, it would show the following features:

Q3 Describe the low power histologic findings. Compare to the reactive lymph node. Reactive

Describe the high power appearance of the lymph node. Q4 Describe the high power appearance of the lymph node.

Q5. What lymphoma have you diagnosed?

Q7. If this patient were to develop worsened anemia as well as jaundice, what would you include in your differential diagnosis? Q8. This patient is likely at increased risk for serious infections. Why?