Are you a Hematology
Morphologist or a Profiler
Kin Cheng, ART
Regional Technical Specialist –
Hematopathology
VGH
Objective
• Define morphologist and profiler
• Discuss the advantages and
disadvantages of being a morphologist
and a profiler
• Use case studies to understand the
importance of providing relevant results to
clinicians.
• Q/A
Hematology Morphologist
• Morphology: The branch of biology that
deals with the form and structure of
organisms without consideration of
function.
• What you see is what you get approach to
report findings on a blood film.
• Example of some blood film morphologies
Morphologist
• Ability to recognize the size, shape, colour
and structure of cells.
• Ability to define the cell type according to
stages of development of each cell line.
• Requires technologist to quantify the
leukocytes as a percentage and grade the
RBC morphologies according to predetermined criteria, e.g. 1+, 2+ etc.
Morphologists
• What you see (and report) may not be
what the patient gets.
• View of the trees, but missing the broader
view of the forest.
• Can be subjective, especially in the
grading of RBC morphologies.
Case 1
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65 yr female
WBC: 7.9
Hgb: 95
MCV 97
Plt 286
Ne: 5.7,
Lym: 0.6
Mono: 1.2
Eos: 0.4
Baso: 0.1
Profiler
• Profiler uses a variety of techniques to gather
information and reports the findings in a
meaning way to clinicians.
• Use information obtained from the slide, CBCD
results, other laboratory test results and relevant
information to report findings.
• Requires better understanding of the correlation
of morphology findings and disease process.
• Reports only relevant information.
Case #1
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Reported present:
Microcytosis
Macrocytosis
Polychromasia
Schistocytes
Case 1
• Clinical history:
• Avid backyard gardener with skin rash on her
hands and body.
• Erythroderma, lymphadenopathy
• Skin biopsy show lymphoid infiltrate of T-cells.
Immunophyenotyping: CD2+, CD3+, CD4+,
CD5+, CD8• Peripheral blood and lymph nodes cells show
lymphocytes with cerebriform nuclei.
• Diagnosis: Sezary syndrome
Obvious Morphologies
• Slide A
• Slide B
(2010-01-12)
(2012-01-27 FR35)
Case 2
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7 year old boy
Aug 20: Vomitting
Aug 21: bloody diarrhea
No fever, but with chills
Aug 20
Aug 27
Aug 28
WBC
5.0
6.2
7.4
Hgb
158
117
85
Plt
238
58
9
BUN
5
9.8
20.1
Creatinine
58
66
111
Case 2
• Differential diagnosis of microangiopathic
anemia:
– DIC
– TTP
– HELLP Syndrome
– HUS
Case 3
• 50 yr male in ICU
• Day 171 post stem cell transplant for AML.
• Developed graft vs host disease. Treated and
discharged.
• Sept 15: admission to ER with worsening
abdominal pain.
• Rapidly falling Hgb despite transfusion support.
• Sept 18: Considered for plasma exchange in the
setting of transplanted-related TTP.
Case 3
• Laboratory Findings:
– Sept 18:
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WBC: 3.73
Hgb: 67
MCV: 84
NRBC: 25%
RDW: 20.5%
RBC Reported:
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Burr cells: Present
Schistocytes: Present
HJB: Present
Dimorphic blood picture: Present
– Sept 18: Gastrectomy, colon biopsy
– Sept 19: Patient expired.
Case 3
Aug 14
Sept 15
Sept 18
Case 3 Bowel Biopsy
PAS Stain
TTP Like Syndromes post BMT
• TTP: thrombocytopenia and MAHA with no
alternative explanation.
• Classic TTP is caused by ADAMTS 13
deficiency.
• Post BMT TTP-like syndrome: Endothelial
cell damage.
(View Youtube at this link below: http://www.youtube.com/watch?v=qO7Kkm6jf9w )
Schistocyte Reporting
• Description:
– Helmet-shape cells
– Fragmented red blood cells
– Small, irregular triangular or cresecentshaped cells, pointed projections and lack of
central pallor
• Automated counting of schistocytes
Schistocytes
• Important to recognize and report
schistocytes as significant finding in MAHA
• ICSH recommendation for schistocyte
counting and reporting:
– Count schistocytes when thrombotic
microangiopathies is suspected.
– >1% of schistocytes is important
Case 4
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70 years old male previously diagnosed CLL.
WBC: 148.8
Hgb: 56, retic 197
MCV: 127
Plt 136
Microcytes present, Macrocytes: marked,
microcytes: present; polychromasia, HJB,
spherocytes
• Important: Must scan slide to determine the
degree of neutropenia.
Case 4
(CLL with AIHA)
• Chemistry results:
– Total Bili: 4. umol/L (0-18)
– LDH: 682 U/L (90-240)
– Haptoglobin: <0.08
Case 5
• 62 yr old male
– previously diagnosed CLL
– Received BMT
– Received IgG
• WBC: 18.1
• Hgb 82
• MCV 94 (Micro, Macro,
– sphero, polychromeasia present)
• Plt 270
• Retic: 222
Case 5
Criteria for IVIG hemolysis as developed by the IVIG hemolysis Pharmacovigilance
Group.
• Onset: within 10 days of IVIG administration
• Lab findings:
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Drop in Hgb 10 g/L
Positive DAT
At least 2 of:
Reticulocytosis
Increased LDH
Low LDH
Unconjugated hyperbillirubinemia
Hemoglobinemia
hemoglobinuria
Significant spherocytosis
Exclude:
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Other causes of anemia, e.g. blood loss, drug-induced, chemo etc
Neg DAT
Absence of other inclusion criteria.
Health Canada:
Canadian Adverse Reaction Newsletter
Vol19, Issue 4. Oct 2009
Interesting facts on IVIG
• Canada is the highest user of IVIG
• Made from a very large pool of human
plasma
• Risk for developing hemolysis includes
Group A or AB patients and very high
dose use (>2 g/kg)
• Cost: $$$$ / treatment
Case 6
• History:
• 26 yr male with some “neuro-degenerative
genetic disorder”.
• Father admitted him to ER because of
“decreasing consciousness”
Case 6
May 17:
• WBC: 12.2
• RBC: 1.06
• Hgb 14 g/L
• MCV: 54
• MCHC: 246
• Plt 140
• Retic: 8 (10-90)
Case 6
• Laboratory follow-up actions
– Check for clots
– Check IV contamination
– Phone to ER
– Recollect
Case 6:
• RBC Morphology Reported:
– Rouleaux :Present
– Microcytosis: Marked
– Hypochromia: Present
– Target cell: occasional
– Tear Drop Cells: occasional
– Elliptocytes: occasional
Case 6
Case 6
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Chemistry:
Iron: 2 umol/L
Iron Binding Capacity: 85 (45-73) umol/L
Fraction Saturated: 0.02 (0.20-0.55)
Folate: 6 (>12) nmol/L
Magnesium: 0.93 (070-1.10 mmol/L
Phosphate: 1.06 (0.80-1.45)mmol/L
B12: 475 (150-600) pmol/L
Diagnosis: Severe iron deficiency
Case 6
• Follow-up:
Date
Hgb
Follow-up
May 17
13 g/L
TM: 2 units
May 18
49 g/L
May 20
TM: 1 unit
May 21
TM: 1 unit
May 23
99 g/L
Case 7
• 50 yr old male
WBC: 7.2
Hgb: 122
MCV: 88
Plt count: 36
INR: 1.6
PTT: 29 s
Fibrinogen: <0.6
Case 7
Case 7
(Acute Promyelocytic Leukemia)
• Bone marrow cytogenetics:
– t(8;17) and t(15;17)
– FISH: PML/RARA fusion
• Coagulation Findings:
– INR: 1.6
– PTT: 24 s
– Fibrinogen: 0.6
Case 7
Thrombocytopenia?
Case 8
• Technologist on microscopy bench review
blood film with the following findings:
Case 9
• ICU patient
• Diagnosis: Severe burn
Case 10
• 65 yr male with fever, night sweat and
chills, and dark urine
• Seen by family doctor: jaundice, blood test
done with Hgb 69.
• Blood film: cold agglutinin present,
reactive lymphocytes present.
• Sent to ER immediately.
• No travel history
• No LN, No hepatospenomegaly
Case 10
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Total bili: 31
Haptoglobin: 0.15
LDH: 525
Normal electrolytes and liver enzymes
Monotest: Positive
DAT: C3d: Positive. IgG: Negative
Dx: Cold AIHA
Case 10
Case 10
• Serology Testing
– Parovirus IgM: Positive, Ig G: negative
– EBV: IgG Positive
– EBV; IgM: not done
– HIV: Negative
Monotest
• Monotest done at VGH:
– Rapid latex slide agglutination test
– Test for heterophil antibody in serum/plasma
– Sensitivity: 99%, Specificity: 93%
– False positive with Parvovirus B19 infection
Case 11
• 45 yr female admitted to ER.
– Returning to BC from summer vacation in a
cottage in NW Washington.
– Sister too sick to travel and admitted to ICU in
Washington
– WBC: 6.4
– Hgb: 130
– Plt: 78
Case 11
Case 12
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76 yr old female
Admitted to ER with acute back pain
10:00 p.m.: alert but seriously ill-looking
WBC: 7.4; Hgb 10, Hct: 0.22; Plt: 324
Case 12
Case 12
• Spun sample to investigate high MCHC
Case 12
Case 12
Case 12
• 1:30 a.m: Intubated at 1:30 a.m.
• 4:00: Ready to transfer patient to an ICU
bed at VGH
• 4:30 DOA
• Diagnosis: Clostridium infection
Body Fluids
• CSF
Cryptococcus
Pleural Effusion
Monomacrophages and
clumps of mesothelial cells
Pleural Fluid
Breast cancer
CSF and Pleural fluid
Melanoma cells
Bacterial
meningitis
Digital Images
• Free link with digital slide library.
• http://www.gpec.ubc.ca:8080/atlas-0.1/
• Future developments
– QA
– Case Studies
• www.secondslide.com : By invitation only
Questions??