ISSUE09

ISSUE

January2021

This issue
Last Month’s Slides P.1
Monthly Case study P.1
Thrombotic thrombocytopenic
Purpura P.2-3
Morphology Top Tips P.3
Bibliography p.3

Last Month’sSlides

December 2020 Slide Monthly Digital Case study
Summaries
Slide 2
Slide 1
Film morphology shows large
granular lymphocytes. Raised
MCHC possible presence of cold
agglutinins. Compare results withcytogenetics and other clinicalresults.

Slide 2Abnormal WBC differential,
thrombocytopenia and alarms onanalyser. Acute B-lymphoblastic
leukaemia. Blast population
estimated at 79% of leucocytes.

Slide 3
Thrombotic thrombocytopenia
purpura (TTP), due to alcohol
binging. Morphology shows
schistocytes, RBC fragments andhelmet cells.

Slide 4Generally normal film

Slide 5Generally normal film

Slide 6
Multiple alarms on the analyser.
>WBC, presence of blasts. 58%
Blastosis.

Presentation
Female 80 years old,Alarms on analyser : WBC Diff abnormal andthrombocytopenia. Acute B Lymphoblastic
Leukaemia at diagnosis. Comment on thereport: Blast population estimated at 79%of leukocytes. Expert comment:
Positive Philadelphia chromosome
Query presence of rare granular blasts.

FBC Results
WBC 43.0 (10^3/mm3)RBC
4.13 (10^6/mm3)
HGB 12.7 (g/L)
HCT
37.6 (%)
MCV 91 (fL)
MCH 30.8 (pg)
MCHC 33.8 (g/dL)
PLT
41 (10^3/mm3)

Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils

13 %
8.3 %
0.9 %
0.9 %
0.0 %

Slide review
Acute B Lymphoblastic Leukaemia at diagnosis.
Comment on the report: Blast population estimated at 79% of leukocytes.
Expert comment: Positive Philadelphia chromosome, query presence of rare
granular blasts.

Diagnosis
Acute B Lymphoblastic leukaemia.

Monthly Morphology
Quiz

Thrombotic
Thrombocytopenic
Purpura (TTP)

Who first discovered
Haemoglobin?

An overview of the clinical features,
laboratory findings and treatment
QSP case 3 slide showing red cell fragments

Introduction
Thrombotic thrombocytopenia purpura (TTP) is an acute disorder characterisedby thrombocytopenia and mircoangiopathic haemolytic anaemia.

Clinical Presentation

please see in the end of

03 December 2020
Female (53 years old)WBC 20.8* (10^3/mm3)
RBC 2.24* (10^6/mm3)
HGB 7.7* (g/dL)
HCT 23.8* (%)
MCV 106 (fL)
MCH 34.4 (pg)
MCMH 32.4 (g/dL)
QSP case 3 slide showing red nucleated RBC
PLT 9* (10^3/mm3)
Thrombotic thrombocytopenic purpura due to alcohol binge drinking.

the newsletter

Laboratory Findings

Haemoglobin Molecule​

For last month’s
crosswords answers,

Several tests to confirm TTP will follow in patients suspected and showing
symptoms of thrombocytopenia and anaemia. Tests include urinalysis, bloodfilm, reticulocyte count, serum LDH, haptoglobin, renal function. ADAMTS13activity, inhibitor assays and serum bilirubin (both direct and indirect).
Confirmed diagnosis would be indicated by:• Thrombocytopenia and anaemia• Blood film showing fragmented red blood cells, indication ofmicroangiopathic haemolysis- schistocytes, helmet cells, distorted red cells• A negative antiglobulin test
• Normal coagulation screen
ADAMTS13 testing is carried out to determine activity and presence of anautoantibody. Although initial treatment should always commence, theresulting ADAMTS13 test can guide as to subsequent treatment. An ADAMTS13level of <10% with the presence of antibody against ADAMTS13 is normal for
adults with TTP, and these patients would respond to a plasma exchange andimmunosuppressants (see below).

Other News

Treatment and Prognosis
Treatment of TTP includes Plasma exchange, corticosteroids, rituximab andvery occasionally caplacizumab.
An untreated thrombocytopenia purpura is almost always fatal. A plasma
exchange has a very successful recovery rate of >85%. The exchange would bestarted urgently and continue daily until results suggest the disease activity
has subsided, i.e., a normal platelet count. Adults with TTP are also oftenprescribed corticosteroids and rituximab.
Calpacizumab, which is an anti-von Willebrand factor single-variable-domain
immunoglobulin, acts by inhibiting the interaction between the unusually large
von Willebrand factor multimers and platelets. Calpacizumab appears tohasten resolution of the thrombocytopenia but can also increase bleeding
tendency of the patient.
Generally, patients will only experience one episode of TTP. However, relapses
occur in roughly 40% of patients who do have a severe deficiency in
ADAMTS13 activity, due to an autoantibody inhibitor to ADAMTS13. If relapse
occurs, more intense immunosuppression using rituximab may be effective.
Patients must be evaluated promptly if relapse is suspected.

Summary
Platelets are destroyed non-immunologically by microvascular thrombi,
resulting in thrombocytopenia, anaemia and organ ischemia.
The cause is a deficiency of the ADAMTS13 protease, commonly due to anacquired autoantibody, but rarely because of an inherited gene mutation.
Morphological features include schistocytes, helmet cells, spherocytes andNucleated red cells.
Untreated TTP is usually fatal. Efficient treatment with plasma exchange
together with corticosteroids and rituximab results in good survival rates.

QSP 2.0

Available as a single
use license and asite license whichallows up to 10
concurrent users. To
find out more,contact us

Bilbliography
Hoffbrand’s Essential
Haematology 7th Edition
Ch.20. Wiley Blackwell
2015
ADAMTS13 gene,
Medline Plus

Editorial Team

This Month’s Top Morphology Tip

Kelly Duffy
Andrew Fisher

Nucleated RBC’s or Lymphocytes??

About us

Nucleated red cells and lymphocytes can sometimes be mistaken. Keycharacteristics too look out for are: The lymphocyte has a viable nucleus withclumpy to blocky chromatin, whereas the nRBCs have pycnotic nuclei withcondensed homogenous chromatin. Cytoplasm colour: The lymphocyte has a blue
cytoplasm whereas the nRBC have a cytoplasm the colour ofmature erythrocytes (red) or immature polychromatophils (purple). Nucleated reds
can be larger than the lymphocyte, but is dependent on the stage of developmentof the red cell.

Nucleated RBC

Nucleated Red CellLymphocyte lhghggh

Lymphocyte

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QSP Newsletter crossword answers

QSP Newsletter crossword questions
Clues Across
1. Term to describe blood cell production in the body (11)
5. Red cell no longer a biconcave disc (10)8. Mature Neutrophil with only one or two lobes is called this (2 words 6-4) (11)
9. Red cells that are shaped like when you cry (2 words 4,4) (9)12. This type of malaria is very neat and have ring forms (10)15. What does the Q stand for in QSP (7)17. Be careful under the mistletoe you might catch this (2 words 9,5) (15)
19. What month is in the name of a stain and the name of a disorder characterised by large platelets (3)22. What species of insect is responsible for transmitting Malaria (9)25. Which company produces Quality Slide Program (6)26. You may aim for this cell (2 words 6,4) (11)29. This lens on a microscope is the closest lens to the slide (9)31. What white cell is the least common in normal blood (8)33. This cell can either be T or B (10)34. This cell may be Russian (6)35. Platelet pre cursor (13)36. If you are Iron deficient your red cells are (10)37. What cell has a normal volume of 9 -12 fl (8)38. Rare hereditary disease where the red cells may look like those from burn patients (18)

Clues Down
2. This disorder can give background stain on the blood film (7)3. Word to describe the changes in red cell shape (14)
4. You use this chamber to count cells manually (8)6. what festive period gives its name to a coagulation disorder (9)7. What feature can be seen in Neutrophils in infection (2 words 4,4) (10)
10. Not a bald cell (10)
11. A monocyte becomes one of these cells when it enters the tissue (10)
13. Immature red cells are characterised by showing this colour change (13)14. Another name for smear cells (6)16. Neutrophils from Females may show this appendage (9)18. A "happy" red cell inclusion 3 words (6,5,6) (19)20. A needle like structure found in blast cells (8)21. These red cell inclusion may be produced by bake bean manufacturers (2 words 5,6) (12)23. Red cells stacked like pennies (8)24. A "mouthy" cell (11)27. To describe difference in the size of red cells (12)28. Red cells you need a supravital stain to manually count (12)30. Most commonly found white cell in normal patients (10)31. What you might find on a castle but also describes the technique of navigating through the slide when performinga differential (10)32. Term to describe red cells larger than normal and seen in B12 or Folate deficiency (10)