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CASE 1

Description:

These normal blood smears show normal red blood cells, white blood cells, and platelets.

Image 1.1:

Image 1.2:

Image 1.3:

Image 1.4:

Image 1.5:

Identify the following:

• Polymorphonuclear leukocytes (PMN's, neutrophils)
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils (may be difficult to find in this smear)

A manual white blood cell differential count consists of a laboratory professional looking at 100 white cells on a peripheral blood smear and enumerating them in the above categories. An automated white blood cell differential count is done by a laboratory instrument that analyzes thousands of white blood cells and either categorizes them as a percentage of granulocytes, lymphocytes, and monocytes, or categorizes them similar to a manual smear using morphometric and/or biochemical parameters.

CASE 2

History:

A 16-year-old boy is brought to the emergency department by his parents becuase he has been complaining of severe abdominal pain for the past day. On physical examination, he had a rigid, board-like abdomen and rebound tenderness in the right lower quandrant. His vital signs include temperature 38.3 C (101 F), pulse 84/minute, respirations 16/minute, and blood pressure 110/65 mm Hg. Laboratory studies include a CBC showing Hgb 14.8 g/dl, Hct 44.4%, MCV 90 fL, platelet count 240,000/microliter, and WBC count 20,000/microliter. A urinalysis is normal. His peripheral blood smear is shown:

Image 2.1:

Questions:

1. What is the predominant white blood cell present?
2. What is the name for this type of leukocyte reaction?
3. What do you think is the diagnosis in this case?

CASE 3

History:

A 15-year-old previously healthy girl is sent home from summer camp because she has exhibited weakness, lassitude, and complaint of a sore throat for the past 3 days. On physical examination she has pharyngeal erythema and enlarged tonsils without overlying exudate. She has several enlarged and slightly tender lymph nodes in her neck. She has a palpable spleen and a tender palpable liver edge. Laboratory studies include a CBC showing Hgb 14.9 g/dl, Hct 44.9%, MCV 92 fL, platelet count 282,100/microliter, and WBC count 12,500/microliter. Her peripheral blood smear is shown:

Image 3.1:

Questions:

1. What is the predominant white blood cell type?
2. What is your diagnosis in this case?
3. What is the differential diagnosis?
4. What other laboratory test may be helpful in arriving at a specific diagnosis?

CASE 4

History:

A 30-year-old man has noted progressive weakness over the past month. On physical examination he has a few small non-tender lymph nodes palpable in both axillae, and the tip of his spleen is palpable. There is also sternal tenderness present on palpation, but no mass lesion or overlying skin changes. Laboratory studies include a CBC that shows Hgb 10.2 g/dl, Hct 30.5%, MCV 88 fL, platelet count 36,000/microliter, and WBC count 67,000/microliter. His peripheral blood smear is shown:

Image 4.1:

Questions:

1. What is the prominennt white blood cell type seen on this smear?
2. Do you see any intracytoplasmic markers which are diagnostic in this case?
3. What is your diagnosis?
4. What do you tell the patient about his chances with a bone marrow transplant?

CASE 5

History:

A 65-year-old man has been in good health except for hypertension treated with a thiazide. On physical examination he has several slightly enlarged non-tender lymph nodes in his neck and both axillary regions. His spleen is palpable. Laboratory studies with CBC show Hgb 11.8 g/dl, Hct 35.6%, MCV 85 fL, platelet count 130,000/microliter, and WBC count 44,500/microliter. His peripheral blood smear findings are shown:

Image 5.1:

The flow cytometry findings are shown:

Image 5.2:

Questions:

1. What is the predominant white blood cell type present?
2. What is the diagnosis?
3. In view of the prognosis for this disease, what are treatment options?

CASE 6

History:

A 52-year-old man has had gradually increasing fatigue for the past 4 months together with worsening discomfort in the left upper quandrant. Physical examination reveals an easily palpable spleen and liver edge. A few slightly enlarged non-tender lymph nodes are palpable in the cervical region. Laboratory studies show Hgb 12.2 g/dl, Hct 36.7%, MCV 93 fL, platelet count 754,000/microliter, and WBC count 246,000/microliter. His peripheral blood smear findings are shown:

Image 6.1:

Image 6.2:

Questions:

1. What type of white blood cells are present?
2. What is the differential diagnosis and how would you resolve it?
3. What is a cytogenetic analysis of the bone marrow likely to show?
4. What is the diagnosis in this case?

CASE 7

History:

A 5-year-old girl has become increasingly listless for the past 2 months. Her mother notes that, whenever she falls or bumps into anything, a big bruise forms. For the past 2 days she has had a high fever. On physical examination vital signs include temperature 39.3 C, pulse 90/minute, respirations 21/minute, and blood pressure 95/60 mm Hg. Laboratory studies show Hgb 9.8 g/dL, Hct 29.6%, MCV 95 fL, platelet count 74,000/microliter, and WBC count 2,300 with differential count 23 segs, 15 bands, 12 monos, 44 lymphs, 5 eos, and 1 baso. A bone marrow biopsy is performed. Her peripheral blood smear is shown:

Image 7.1:

The findings on flow cytometry are shown:

Image 7.2:

Questions:

1. What type of white blood cells are present?
2. What is the most likely diagnosis?
3. What is the most likely outcome of this child's disease with standard therapy?
4. What other test could be helpful in distinguishing the nature of the cells in this case?

CASE 8

History:

A 3 year old boy has had multiple episodes of pneumonia with Staphylococcus aureus and urinary tract infections with beta-hemolytic Streptococcus in the past 6 months. He had been born at term to a 22-year-old woman. He was noted at birth to have no congenital anomalies. He did well during infancy. His only sibling, a 5-year-old sister, has had no major medical problems. On physical examination he has blond hair and blue eyes (everyone else in the family has a darker complexion). He has contusions of multiple ages on his extremities. A CBC shows Hgb 13.8 g/dL, Hct 41.5%, MCV 85 fL, Platelet count 176,000/microliter, and WBC count 4,080/microliter with differential count of 45 segs, 2 bands, 40 lymphs, and 13 monos. Serum quantitative immunoglobulins show IgA 71 mg/dL (16 - 83 mg/dL), IgG 901 mg/dL (282 - 1026 mg/dL), and IgM 109 mg/dL (39 - 142 mg/dL). His peripheral blood smear is shown:

Image 8.1:

Questions:

1. Describe the laboratory findings. What conditions can be included or excluded?
2. What abnormality is present on the smear?
3. What is the most likely diagnosis?
4. What is the underlying abnormality?
5. What other tests could be helpful in distinguishing other related conditions?