ISSUE03

ISSUE

July
2020

This issue
Last Month’s Slides P.1
Monthly Case study P.1
Morphology in Covid 19 P.2/3
Monthly Quiz P.2
Top Tips P.3

Last Month’sSlides
June 2020 SlideSummaries

Monthly Digital Case study

Slide 1

Presentation

Occasional myelocyte, relativemonocytosis. Giant platelet

Slide 2
Generally normal film, occasional
atypical lymphocyte

Slide 3
Acute myelomonoblastic leukaemia
with 83% blasts andpromonocytes. N’RBCs

Slide 4
Myelodysplastic blood film withexcess blasts. Hypogranularmyeloid cells 15% blasts

Slide 5
Eosinophilia+++IgE hypergammaglobulinemia
syndrome

June 2020 Slide 4
Male (87 years old)
Follow up of known MDS with excess of blasts

FBC ResultsWBC
96.5 (10^3/mm3)RBC
2.50 (10^6/mm3)
HGB
82 (g/L)
HCT
24.7 (%)
MCV
99 (fL)MCH
33.0 (pg)
MCHC 33.4 (g/dL)
PLT
41 (10^3/mm3)
N’RBCs 7/100 WBCs

Neutrophils
44.2%
Lymphocytes
3.1%
Monocytes
20.6%
Eosinophils
0.8%Basophils
1.5%
Metamyelocytes 2.3%
Myelocytes
9.2%
Promyelocytes 0.8%
Blasts17.5%

Slide review
A challenging slide with multiple dyscrasia
Myelodysplasic blood film with hypogranular and hypersegmented neutrophils. Somewith nuclear extensions
No Auer rods seen.
Blasts and promonocytic cells present
Monocytosis – monocytes with vacuoles
Blood film confirms thrombocytopaenia

Slide 6

Anisocytosis +++ with microcytic and macrocytic RBCs, poikilocytosis and occasional
spherocyte

Myelocytes and occasional blast
Some hypogranular polymorphs
Myelodysplasia

Diagnosis
Myelodysplastic syndrome in transformation to probable
acute myeloid leukaemia.
Immunophenotyping requiredBloodMorphology
in Covid 19patientsMonthly Morphology
Quiz
Look closely at thesecells:

An overview oflaboratory findings
Introduction
Many quantitative hematologic abnormalities have been describedin the first patient studies of COVID‐19, the disease caused by theSARS‐CoV‐2 virus. In addition to this, a number of studies haveexplored morphological changes that accompany the disease atdifferent stages and different degrees of severity.

What is unusual about themand what could thisIndicate?

Last month’s cells:

Haematology
From a haematology perspective, reduced levels of lymphocytes, haemoglobin
and platelets have been noted. Lymphocytopaenia has been indicated in up to85% of severe cases, with its severity linked to outcome. The
neutrophil/lymphocyte (N/L) ratio being cited as a useful indicator.
In addition to low lymphocytes, blood counts may also show leucocytosis withneutrophilia and monocytopaenia initially with subsequent improvement in thenumber of monocytes from the fifth day onwards.
The most common haematological findings include:• Lymphocytopaenia, neutrophilia• Mild thrombocytopaenia (35%) or, less common, thrombocytosis.
• The occasional presence of atypical, reactive lymphocytes• A mild leuco‐erythroblastic picture was observed in the peripheral bloodfilm in a report from California

Blood Morphology
Early research suggests that peripheral blood films of a patient with COVID19 may show certain morphological features:

The blood film shows
acanthocytes andspherocytes.
The blood film was from apatient with haemolytic
anaemia.

• Neutrophils may show heavily clumped chromatin with toxic granules andcytoplasmic vacuoles• Abnormal Neutrophils with C-shaped, foetus-like nuclei have been noted,
some with nuclear projections, named by one study as ‘COVID nuclei’• Activated monocytes could be a favourable sign
• Large granular lymphocytes with some atypical features

BloodMorphology inCovid 19
patients
Continued frompage 2
Blood Morphology Continued…
Lymphocytes were described as large granular lymphocytes (LGL) with roundto indented nuclei, condensed chromatin, prominent nucleoli in a few, alongwith abundant pale blue cytoplasm with distinct variably sized azurophilic
granules (see above). Cytoplasmic pod formation and apoptosis were also
observed in a few lymphocytes. These could represent natural killer cells or
cytotoxic T lymphocytes.

Conclusion
The understanding haematological changes in SARS-CoV-2 is still evolving. To
reach a definite conclusion regarding the specificity and reliability of theseabnormal features in peripheral smears, more COVID-19 positive patientsneed to be evaluated in larger studies.
If confirmed, these morphological features along with blood count will be
helpful in the screening, diagnosis, and management of these patients

This Month’s Top Morphology Tip

Other NewsQSP 2.0
Available now!
Options for a single
operator or site
license which allows
up to 10 concurrent
users

Bibliography
BMJ Morphology of
COVID-19–affected cells
in peripheral blood film
Aminder Singh et al
AJH - Morphologicalanomalies of circulating
blood cells in COVID ‐19
Gina Zini et al
QSP June 2020

Editorial Team
Kelly Duffy
Mandy Campbell
Shubham Rastogi

Performing a manual differential• Usually done by counting 100 leukocytes• Scan the slide to find where the cells are optimally spread (monolayer) andswitch to 50 or 100x oil immersion objective• Begin counting the white cells moving back and forth across the slide in apattern that avoids covering the same area
• Ideally this is done by moving sideways in a "battlement pattern"• Identify each leukocyte 100 cells have been counted, identified by type• This will provide a percentage of each leukocyte type or a relative
differential leukocyte count

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