430-Hematology and Hemostats II

430-Hematology and Hemostats II

WEEK 2 Case Study

A 40-yr-old woman presents with fatigue, weight loss, weakness, pallor, and petechiae. She recently had viral pneumonia while traveling in Europe and was treated with Chloromycetin. A CBC was ordered and the results are as follows:

CBC
WBC (x 109/L) 2.00
RBC (x 1012/L) 2.90
HGB (g/dL) 8.3
HCT (%) 25
RBC INDICES
MCV (fl) 86.2
MCH (pg) 28.6
MCHC (g/dL) 33.2
RDW (%) 12.5
PLT (x 109/L) 30

DIFFERENTIAL
WBC identification Relative (%)
segs 14
lymphs 80
monos 6
eos 0
basos 0

Platelet estimate 2/ OIF

QUESTIONS
1. Are the above results within the normal range? If not, indicate those that are outside the reference range.
2. (a) Calculate the absolute counts for each of the white blood cell types – show
all your work.
(b) Are these absolute counts within the normal range? If not, indicate those
that are outside the reference range.
3. How would you describe her red cells morphologically (i.e. normo-, macro-or
microcytic; hypo- or normochromic)?
4. In what conditions would you see similar CBC and differential results? Be specific.
5. Correlate her clinical findings with her CBC/differential results.

A bone marrow aspirate and biopsy were collected. The results are as follows:
less than 5% cellularity, 95% fat; lymphocytosis and plasmacytosis present;
2+ iron stores

6. Why was a bone marrow ordered in this case?
7. Why was the marrow biopsy sample important to acquire in this case?
8. (a) How do you determine iron stores in bone marrow samples?
(b) What is the significance of the 2+ iron stores seen in this patient?
9. Based on the patient’s clinical history, physical exam and test results, what
disorder is the patient most likely suffering from? Justify you answer. Be
specific.
10. What was the most likely cause for her condition?

WEEK 3 Case Study
A 70-yr-old male, who had been getting progressively more tired and lethargic the past few months, sought medical advice. The patient appeared thin with noticeable pallor of the nail beds and mucus membranes. A CBC revealed his H&H to be 9.1 g/dL and 30.0%. He was placed on iron supplementation and told to return for follow-up blood work in six weeks. Six weeks later his hematocrit had dropped to 25.7% (see CBC below). CBC
WBC (x 109/L) 4.0
RBC (x 1012/L) 2.10 HGB (g/dl) 8.5
HCT (%) 25.7 RBC INDICES MCV (fl) 122 MCH (pg) 40
MCHC (g/dl) 33
RDW (%) 21
PLT (x 109/L) 120
RETIC COUNT (%) 0.7

DIFFERENTIAL WBC identification Relative (%) Absolute (x109/L)
segs 40 1.6 lymphs 49 2.0
monos 8 0.3 eos 3 0.1 basos 0 0.0

RBC morphology Moderate poikilocytosis, moderate anisocytosis, several ovalocytes,
occasional Howell-Jolly bodies, neutrophils with 6 lobes noted.
Platelet estimate 7 / OIF

QUESTIONS
1. Are his CBC and differential results within the normal range? If not, indicate those
that are outside the reference range.
2. How would you categorize his red cells morphologically (i.e. normo-, macro-or
microcytic; hypo- or normochromic)?
3. In what conditions would you see similar CBC results? Be specific.

Based on the clinical history and CBC results above, chemistry testing was performed and the following results obtained:
Sodium = 140 mmol/L
Potassium = 4.6 mmolL
Chloride = 99 mmol/L
Bicarbonate = 26 mmol/L
AST = 30 U/L
ALT = 38 U/L
Glucose = 92 mg/dL
Total bilirubin = 0.9 mg/dL
Serum iron= 82 ug/dL
Serum ferritin = 70 ug/L
B12 = 312 pg/ml
Folate = 2.0 ng/ml (serum level– radioassay)

4. Are his chemistry results within the normal range? If not, indicate those that are outside the
reference range.
5. What information do the ALT and AST results provide concerning this patient?
6. What disorder is suggested by the clinical history and test results on this patient? Justify
your answer.
7. Bone marrow
(a) Describe the characteristic appearance of the bone marrow in this disorder.
(b) Discuss the mechanism responsible for these characteristic bone marrow findings.
8. (a) Calculate the absolute reticulocyte count – show all your work. Is it normal or abnormal?
(b) Based on your diagnosis, is this the result you would have expected?
9. Schilling Test
Review the results of the Schilling test below and suggest the most likely diagnosis based on
these findings. Explain your answer.
-Part I, before intrinsic factor = 6.0%
-Part II, after intrinsic factor = 8.0%
10. Why do you think his hematocrit continued to drop after iron supplementation?

Week 4 Case Study A 38-yr-old female is diagnosed with pneumonia and is treated with high-dose intravenous penicillin. An initial CBC is normal except for an elevated leukocyte count with a left shift. She returns to her physician 1 week later complaining of lethargy. The physician notes that the sclera of her eyes now appear yellow. A CBC and a chemistry panel are ordered. The results are as follows: CBC
WBC (x 109/L) 12.5
RBC (x 1012/L) 2.80
HGB (g/dl) 8.0 HCT (%) 24.9 RBC INDICES MCV (fl) 88.9 MCH (pg) 28.6 MCHC (g/dl) 32 RDW (%) 15.5 PLT (x 109/L) 310
RETIC COUNT (%) 3.5

DIFFERENTIAL WBC identification Relative (%) segs 66
bands 7
lymphs 21
monos 5 eos 1 basos 0

N RBC 2

RBC morphology Slight anisocytosis, slight polychromasia, few spherocytes
Platelet estimate 18 /OIF

CHEM PANEL:
Sodium = 140 mmol/L
Potassium = 4.2 mmol/L
Chloride = 100 mmol/L
Bicarbonate = 25 mmol/L
AST = 26 U/L
ALT = 30 U/L
Glucose = 92 mg/dL
Total bilirubin = 2.8 mg/dL
Serum iron= 170 ug/dL
LD = 400 U/L
BUN = 6.0 mg/dL
Creatinine = 0.6 mg/dL

QUESTIONS
1. Are her CBC and differential results within the normal range? If not,
indicate those that are outside the reference range.

2. How would you categorize her red cells morphologically (normo-, macro-
or microcytic; hypo- or normochromic)?
3. (a) Calculate the absolute counts for each of the white blood cell types – show
all your work.
(b) Are these absolute counts within the normal range? If not, indicate those
that are outside the reference range.
4. What is the significance of the nucleated rbcs and the rbc morphology noted on this
patient? Be specific.
5. Discuss her chemistry panel results with regards to her current medical condition.

The physician subsequently ordered a DAT. The results are:
2+ polyspecific, 1+ anti-IgG, negative anti-C3b

6. What is the rationale for ordering DAT testing on this patient?
7. What do the results of the DAT imply about this patient’s medical condition?
8. Based on the clinical findings and lab results, what is the most likely
cause of this patient’s anemia? Justify your answer.
9. Describe the mechanism that is the most probable cause of this
patient’s anemia.

WEEK 5 Case Study C
A 59-year-old female has been experiencing weakness and excessive fatigue over the past 10 weeks. She decides to see her physician because she begins experiencing pain in her left upper abdomen. Physical examination reveals an enlarged spleen. The results of laboratory testing are as follows: CBC
WBC (x 109/L) 102.0
RBC (x 1012/L) 2.99 HGB (g/dl) 9.8 HCT (%) 29.1 RBC INDICES MCV (fl) 97.3 MCH (pg) 32.8 MCHC (g/dl) 33.7 RDW (%) 18.2 PLT (x 109/L) 580 DIFFERENTIAL WBC identification Relative (%) segs 13 band segs 28
metamyelocytes 15 myelocytes 8 promyelocytes 6
lymphs 15 monos 6 eos 4 basos 6

RBC morphology Slight anisocytosis
Platelet estimate 29 /OIF

ADDITIONAL TESTING
-LAP (leukocyte alkaline phosphatase): 100 band and segmented neutrophils were
counted and the cells’ reactivity was scored as follows:
• Cells with a negative (0) reaction = 92
• Cells with a positive 1+ reaction = 5
• Cells with a positive 2+ reaction = 3

-Lactate dehydrogenase (LD): 587 IU
-Uric Acid: 7.8 mg/dL

QUESTIONS:
1. What is the significance of this WBC count and differential?
2. How would you categorize her cells morphologically (normo-, macro- or microcytic;
hypo- or normochromic)?
3. (a) Why was an LAP performed on this patient?
(b) Calculate this patient’s LAP score
(c) How would you interpret the calculated LAP score?
4. Are the LD and uric acid results normal? If not, suggest the likely cause(s) for the
results seen here.
5. Based on the information provided, what is the likely diagnosis? Justify your answer.
6. A bone marrow was performed to confirm the diagnosis. What would you expect this
patient’s bone marrow to look like? Be specific in your description.
7. Cytogenetic studies were also ordered.
(a) Briefly explain how cytogenetic studies (karyotyping) are performed.
(b) Justify the use of cytogenetics in this case.
8. Discuss the prognosis and treatment of this disorder.

Week 6 Case Study C
A 43-year-old man is seen by his primary care physician. He complains of excessive tiredness and a lack of stamina in activities he typically performs (work, sports). He recently noticed excessive bleeding from his gums after brushing his teeth. On physical examination, his physician noted lymphadenopathy and multiple petechiae on his torso, arms and legs. A CBC with differential and a coagulation panel were ordered. The results are as follows: CBC
WBC (x 109/L) 25.0
RBC (x 1012/L) 2.80 HGB (g/dl) 8.4 HCT (%) 24.1
RBC INDICES MCV (fl) 86.1
MCH (pg) 28.9 MCHC (g/dl) 34.9
RDW (%) 14.2 PLT (x 109/L) 29

DIFFERENTIAL WBC identification Relative (%) Absolute (x 109/L) segs 3 0.8
lymphs 11 2.8
monos 2 0.5 eos 0 0 basos 0 0
promyelocytes 76 19.0
blasts 8 2.0

RBC morphology: Normocytic, normochromic; few schistocytes noted.
Platelet estimate 2/ OIF

COAGULATION PANEL
PT = 16.4 seconds (reference range 11.0 -13.0 seconds)
APTT = 42.0 seconds (reference range 21.0-35.0 seconds)
TT = 15.2 seconds (reference range 7.0-12.0 seconds)
FIBRINOGEN = 78 mg/dL (reference range 200-400 mg/dL)

QUESTIONS
1. Identify the abnormal results seen in the laboratory testing performed on this patient.

A bone marrow aspirate and biopsy were performed. The BM was hypercellular with few blasts; promyelocytes were the predominant cell and many contained bundles of Auer rods. Megakaryocytes were absent. Cytochemical staining was completed on the BM sample with the results as follows:
Myeloperoxidase positive
Sudan Black B positive
Chloroacetate esterase positive
Alpha-naphthyl butyrate esterase negative
Periodic Acid Schiff negative

2. Does this patient’s test results suggest an acute or a chronic disorder? Justify your
answer.
3. Explain why cytochemical staining was ordered on this patient.
4. For EACH cytochemical stain listed above,
(a) state what specific cellular component (i.e. enzyme, glycogen, lipid) is
reacting with the stain
(b) identify which cell line(s) will react with the stain.
5. Cytogenetic analysis was also ordered on this patient. A translocation of the long
arms of chromosomes 15 and 17 was identified.
(a) Briefly describe how cytogenetic analysis is performed.
(b) Discuss the clinical use for cytogenetic analysis in hematology.
6. Based on the physical exam results and all the laboratory data, what would the FAB
and WHO classification (group and subgroup) be for this patient?
7. Based on your answer to question #6:
What result would you predict for EACH of the following cell markers using
monoclonal antibodies?
CD10, CD13, CD33, CD34, CD11b, CD14, Glycophorin A, HLA-DR
8. Explain the likely cause for the coagulation results seen on this patient.
9. What is the prognosis and likely therapeutic regimen for someone with this disorder?

Week 7 Case Study

A 16-month-old male is brought to his pediatrician for a check-up. His mom has noticed that he seems to bruise easily and it has become more apparent since he has started walking and climbing. Physical exam reveals a few ecchymoses but is otherwise unremarkable. Questioning revealed that two maternal uncles were “bleeders”. The child is not on any medications. A CBC was ordered – the results were as expected for a child his age. A coagulation screening panel was also ordered. The results are as follows:

Coagulation screening panel:
PT = 13.4 seconds (reference range 12.0 -14.2 seconds)
APTT = 44 seconds (reference range 28.0-35.5 seconds)
TT = 13 seconds (reference range 11.0-16.0 seconds)
Platelet count: 360.0 x 109/L (reference range 150.0-450.0 x 109/L)

Reflex Testing:
(1) Mixing Study APTT: 35.0 seconds (normal 28.0-35.5 seconds)

(2) Factor Assays:
F VIII = 4% (reference 50-150%)
F IX= 128% (reference 50-150%)
F XI = 112% (reference 50-150%)

(3) Bleeding Time: 4 minutes (reference range 1-9 minutes)

QUESTIONS
1. Discuss this patient’s physical exam findings, clinical history and family history with
regards to the evaluation for bleeding disorders.
2. Discuss EACH of the 4 tests that are part of the screening panel including (a) why
each test was included in the panel and (b) how each test is performed. Be specific
in your answer.
3. Why was reflex testing performed on this patient?
4. Mixing Studies
(a) Discuss the purpose of a mixing study.
(b) How are mixing studies performed?
(c) How would you interpret this patient’s mixing study?
5. Factor assays
(a) Describe how factor assays are performed
(b) How would you interpret this patient’s factor assay studies?
6. Bleeding Time
(a) What is the purpose of performing a bleeding time?
(b) How is the test performed?
(c) How would you interpret this patient’s bleeding time?
7. Based on the history, physical exam and coagulation testing performed, what is this
patient’s most likely diagnosis? JUSTIFY your answer.
8. What therapy is typically used for bleeding episodes in individuals with this disorder?
9. Platelet aggregation studies may be part of the coagulation reflex testing
protocol.
(a) Why are platelet aggregation studies performed?
(b) Describe how platelet aggregation studies are performed.
(c) Would a platelet aggregation study be needed on this patient? Justify your
answer.

 

 

 

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