ISSUE02

ISSUE

June
2020

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

Last Month’sSlides
May 2020 SlideSummaries

Monthly Digital Case study

Slide 1

Presentation

Generally normal film, mild
leucopaenia, occasional atypicallymphocyte

Slide 2
Generally normal film, basophilia

Slide 3
Blasts present. Neutropaenia,basophilia, anisocytosis,
thrombocytopaenia. Known AML

Slide 4
Blastoid form of mantle celllymphoma. Additional
myelodysplastic features

Slide 5
Reactive, plasmacytoid
lymphocytes

Slide 6
Reactive lymphocytes
Thrombocytopaenia
Malaria - trophozoites(see case study opposite)

May 2020 Slide 6
Male (27 years old)
Patient hospitalized following a return from Togo (a duration of approximately 3months).
Difficulty eating, body aches, fluctuating fever, fatigue.

FBC Results
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
PLT

7.2 (10^3/mm3)3.38 (10^6/mm3)
116 (g/L)
34.5 (%)
102 (fL)
34.5 (pg)33.7 (g/dL)
46 (10^3/mm3)

Neutrophils
Lymphocytes
Monocytes
EosinophilsBasophils

81.1%
12.9%
2.9%
0.7%
1.4%

Reactive/plasmacytoid lymphocytes

Slide review
Examination of the blood film confirms thrombocytopaenia.
The most distinctive feature is the presence of somedeeply basophilic lymphocytes, some with an offset
nucleus, characteristic of plasma cells.
Examination of the red cell/platelet images,
reveals a number of trophozoites (ring-forms) of Malaria.
The trophozoites were compact.
No schizonts or gametocytes or multiple parasitaemia.

Diagnosis
The trophozoites appear characteristic of Plasmodium Falciparum.
Standard staining for malaria is Giemsa staining at pH7.2,not MGG
at pH6.8. Confirmatory malaria screening films should be reviewed.
Thrombocytopaenia is also indicative of Malaria
Atypical lymphocytes have been observed in Malaria but it is notpossible to rule co-morbidities. Viral studies recommended.

Monthly Morphology
QuizMantle Cell
Lymphoma –In Brief

Name these cells:

An overview of theclinical features,
laboratory findings andtreatment
Introduction
What term is used for thered cells in the picture
above?
What is a possible diagnosisfor the patient?

Last month’s cells:

Mantle Cell Lymphoma is a rare sub-type of Non-Hodgkin’s Lymphoma. It is a
B-cell lymphoma that develops from an area of the lymph node known as themantle zone.
It accounts for 2-7 percent of NHLs in the US and Europe and is characterized
by a t(11;14)(q13;q32) translocation

Clinical Presentation
The disease primarily affects men over the age of 50 year presenting withnormally painless lymphadenopathy. Many affected individuals havewidespread disease at diagnosis, with involved regions often including multiple
lymph nodes, the spleen, and, potentially, the bone marrow, the liver, and/or
regions of the gastrointestinal tract.
Individuals may also present with non-specific symptoms or symptoms relating
to bone marrow infiltration.
Genetics
Cytogenetic analyses have revealed that MCL is closely associated withthe t(11;14)(q13;q32). This translocation juxtaposes Ig heavy chain gene (IGH)
sequences with the BCL-1 locus, leading to up-regulation of the CCND1 geneand consequently to an overexpression of cyclin D1. The presence of thistranslocation is required for diagnosis. Other mutations are usually present

The blood film shows
basophilic stippling, with amicrocytosis.
Laboratory results show aHb, Hct and MCV, giving riseto the microcytic anaemia.
Basophillic stippling occurs inlead poisoning, haemolytic
anaemia, thalassemia, MDS,
Due to ncreased ribosomes
in red cells
Further testing for leadpoisoning - Prussian blue, tolook for presence ofsideroblast rings.

Laboratory Findings
The peripheral blood may be normal on presentation but bone marrow
infiltration is common with mantle cell lymphoma.
• In advanced disease with bone marrow involvement, there may be anaemia,neutropaenia and/or thrombocytopaenia.
• The abnormal ‘Mantle cells’ may be seen in the peripheral blood. There areseveral variants of mantle cell including the ‘blastoid’ cells illustrated above.
• Serum Lactate Dehydrogenase (LDH) is frequently raised and may indicate
rapidly proliferating disease• Uric acid may be elevated• Cells are CD5 positive
Treatment and Prognosis
Current treatment regimes include chemotherapy such as R-CHOP(rituximab in combination with cyclophosphamide, hydroxydaunorubicin,
vincristine (Oncovin) and prednisolone). Ibrutinib is used in relapsed
cases and early disease. Stem cell transplantation.

Prognosis is relatively poor but 15% of cases follow a more indolent
course, similar to CLL.

Other News

Auer RodsQSP 2.0

A diagnosticmorphology
feature.

Coming soon!

Introduction

Bilbliography

Auer rods are seen in certain white blood cells and can be used to assist in theclassification of leukaemias. They are named after the American Physiologist
John Auer, although they were first described in 1905 by a Canadian physicist
named Thomas McCrae.

Hoffbrand’s Essential
Haematology 7th Edition
Ch.20. Wiley Blackwell
2015

What are they?

QSP May 2020

Available as a single
use license and asite license whichallows up to 10
concurrent users

Auer rods (or Auer bodies) are large, crystalline cytoplasmic inclusion bodies,
which form elongated red-staining needles. They are composed of fusedlysosomes and contain peroxidase, lysosomal enzymes and large crystalline
inclusions.

https://onlinelibrary.wile
y.com/doi/full/10.1002/ajh.24797

What do they indicate?
They may be seen in myeloid blast cells during acute myeloid leukemia , acutepromyelocytic leukaemia(M3) , and high grade myelodysplastic syndromes
and myeloproliferative disorders cells under microscopic examination.
The identification of Auer rods is very significant, as when found, they canconfirm the presence of myeloblasts, indicating the presence of a nonlymphocytic (myeloid) leukaemia. This differentiation is important, astreatments vary between lymphoblastic and myeloblastic leukaemia.

Auer rods can cause disseminated intravascular coagulation (DIC) due to thegranules in the malignant promyelocytes containing a substance which rapidly
activates the coagulation cascade. As many traditional chemotherapy agents
cause cell lysis and the release of procoagulant substances, this puts thepatient at a higher risk of disseminated intravascular coagulation (DIC).

This Month’s Top Morphology Tip
LOW POWER!
Don’t forget to use your low power objective when examining a manual
blood film. It’s ideal for getting and overview of the slide - quality,
cellularity, cell distribution, as well as selecting the best viewing area for a
WBC differentialEditorial Team
Kelly Duffy
Mandy Campbell
Shubham Rastogi

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