SNMIH

Department Of Pathology

CASE STUDY
SNMIH
A 5-year old boy presented with

 Fever, weakness , bleeding from mouth & nose

 Generalized lymphadenopathy
 Hepatosplenomegaly

Laboratory Findings

 Hemoglobin : 6.5 g/dL

 TLC: 54 x 103 /µL
 DLC: lymphoblast80 L12M4E4
 Platelet Count : 34 x 103/µL

Bone Marrow Aspirate

 Hypercellular, full of blast cells.

 Sudan Black B & Myeloperoxidase staning: Negative in the blast cells.
 Immunophenotyping: Monoclonial mature B-cell markers present.

Bone marrow Aspirate smears

Questions
1. Give your Diagnosis.
2. Give point s in Favour of your diagnosis.
 An 8-Year old boy presented with

 Severe anemia
 Recurrent bouts of severe abdominal pain
 Haematuria
 Growth retardation

LABORATORY INVESTIGATIONS:

 Haemoglobin: 4.0 g/dL

 TLC: 11.0 x 103/µL
 Platelet count: 212x 103/µL
 Reticulocyte count: 12%
 GBP
 Anisopoikilocytosis of red cells
 Elongated sickle like cells
 Target cells
 Polychromatic cells
 Fragmented cells

PERIPHERAL BLOOD SMEAR:

 Haemoglobin Electrophoresis: SS pattern

Questions

 What is your diagnosis?

 What is the genetic defect in this condition?
A 65-year old male presented with
 Lethargy, weakness, easy fatigability
 Generalized Lymphadenopathy
 Hepatosplenomegaly

Laboratory Investigations
 Haemoglobin : 10.0 g/dL
 TLC: 120 x 103 /µL
 Platelet count : 160 X 103 /µL
 DLC: L85 N10 E3 M2
 Smear cells (basket cells)present.
 Immunophenotyping: Markers for CD19, CD20, CD23 & CD5 positive

Peripheral Blood Smear

QUESTIONS

 Give your diagnosis ?

 Give points in favour of your diagnosis ?
 Enumerate three other causes of lymphocytosis ?
A 10-year old girl presented with
 Severe anaemia
 Koilonychia
 Smooth and sore tongue

Laboratory Findings
 Haemoglobin: 5.7g/dL
 MCV: 65 fL
 MCH: 15 pg
 RDW: 20.6%
 Platelet Count: 530 x 103 /µL
 Serum Iron: 30 µg/dL
 Serum TIBC : 500 µg/dL
 Serum Ferritin: 4.8 µg/dL

Peripheral blood smear and red cell morphology

Questions:
 Give your diagnosis ?
 Give points in favour of your diagnosis ?
 Name few other causes of microcytic hypochromatic anemia?
A 32- year old male presented with

 Anemia
 Fever
 Splenomegly

Laboratory Investigations

 Haemoglobin: 4.5 g/dL

 TLC: 70 x 103/µL
 Platelet Count: 80 x 103/µL
 DLC:
 Blasts: 25%
 Prpmyelocytes: 05%
 Myelocyte : 10%
 Metamylocytes : 08%
 Neutrophils: 32%
 Lymphocytes: 20%
 Sudan black B & Myeloperoxiase staining of the blat cells: Positive.

Bone marrow Aspirate smear

Questions
 Give your diagnosis?
 Give points in favour of your diagnosis?
A male child of 5 years age presened with the history of irregular fever,
sore throat, casy fatigulability, weight loss, generalized
lymphadenopathy and bleeding gums.

Blood Findings:
 Hb%: 6.0 gms%
 T.L.C: 30,000/cmm
 DLC:
 Lymphoblasts: 45%
 Mature Lymphocytes: 45%
 Neutrophils: 08%
 Monocyte: 02%
 R.B.C are normocytic with moderate degree of hypocromatic
,anisocytosis. Poikelocytosis with small number of nucleated cells(1%
of leukocyte)
 Reticulocyte: 3%
 Platelates: 40,000/cmm

GIVE YOUR DIAGNOSIS ?

 A 15-year old boy presented with
 Anemia
 Recurrent jaundice
 Hepatosplenomegaly
 Gall stones

Family history confirme similsr disease in his father.

LABORATORY INVESTIGATIONS:
 Haemoglobin: 6.0 g/dl
 WBC :4.5X10/µL
 Platelet count: 200 X 103 /µL
 DLC: N40 L57 E1 M9
 Reticulocyte count: 28%
 GBP:
 Densely haemoglobinized red cells (spherocytes)
 Polychromatic cells
 Basophilic stippling
 Osmotic fragility of red cells: Increased
 Coomb's test:

PERIPHERAL BLOOD SMEAR:

QUESTIONS:
 What is your diagnosis?
 What is the genetic defect in this condition?
A 22-year old old male presented with

 Anaemia, anorexia, weight loss

 Gastritis, diarrhea
 Skin hyperpigmentation

LABORATORY INVESTIGATIONS:
 Haemoglobin: 6.8g/dL
 RBC count: 1.5 x 106/µL
 MCV : 133 fL
 MCHC: 30%
 RDW: 18.5%
 TLC: 1.8 x 103/µL
 Platelet Count: 48 x 103/µL
 Serum LDH: 8800 U/L

PERIPHERAL BLOOD & BONE MARROW SMEARS

Questions:
 What is your diagnosis?
 Give points in favour of your diagnosis?
 What are the causes of this abnormality?
A young girls with history of cough and fever for six months. Presented
in the hospital with following complaints.
Severe headache for last 10 days and Boults of vomiting for about a
week.

Her C.S.F Examination revealed following abnormalities:

 Appearance: Straw coloured
 Sugar: 30mg/100 ml
 Protein: 200mg/100 ml
 Chloride: Lower side of normal range
 Cells: 200 cells/cmm (mostly Lymphocytes)

GIVE YOUR DIAGNOSIS ?

A 35-year-old male presented with

 Anaemia
 Fever
 Bleeding from nose
 Petechial hemorrhages

LABORATORY INVESTIGATIONS:
 Haemoglobin: 4.5g/dl
 TLC: 80 x 103/µL
 DLC:
 Promyelocytes: 70%
 Myelocyes: 10%
 Neutrophils:10%
 Lymphocytes: 10%
 Platelet count:30 x 103/µL
 Sudan Black B & Myeloperoxidase staining of the bone marrow blasts & promyelocytes: Strongly
positive.
 Cytogenetic study: t(15;17)(q22;q12)

BONE MARROW ASPIRATE SMEARS:

QUESTIONS
 What is your diagnosis?
 Give points in favour of your diagnosis?
A 33-year-old male presented with insidious onset of

 On and off fever, excessive sweating

 Weight loss, fatigue, bone pains
 Massive splenomegaly

Laboratory investigations

 Haemoglobin: 8.0g/dL
 TLC: 180 X 103 /µL
 DLC:
 Myeloblasts: 04%
 Promyelocytes: 08%
 Eosinophils: 07%
 Neutrophils: 36%
 Basophils: 08%
 Myelocytes: 24%
 Lymphocytes: 01%
 Metamyelocytes: 12%
 Platelet count: 550 x 103 /µL
 LAP score: 2( normal: 40-100)
 Cytogenetics: Philadelphia chromosome +
 Molecular genetics: BCR-ABL fusion gene +

Peripheral blood smears:

Questions

 Give your diagnosis?

 Give points in favour of your diagnosis?
 Name few other chronic myeloproliferative disorders?
A three year old child presenting with sever anaemia failure to
thrive, recurrent fever, jaundice and spelnomegly.
Blood Picture:
 Hb% :4.0 gms%
 I.R.C : 2.5 million/ cmm
 PCV: 15%
 MCV: 60fL
 MCH: 16Pg
 MCHC: 27%

Red cells are microcytic with marked hydrochromia and showing severe degree of
anisocytosis and Poikelycytosis. Besides these there are 30% Target cells and 5%
normoblasts. Red cells also shows Polychromasia and punctate basophili

 TLC: 25,000/cmm
 DLC:
 Neutrophils: 75%
 Metamyelocytes: 3%
 Myelocytes: 2%
 Lymphocytes: 15%
 Monocytes : 5%
 Platelets: 180,000/cmm

Osmotic fragility curve shows increased resistance to haemolysis

 Serum bilirubin : 3mg%

 Serum iron : 210 microgram %

GIVE YOUR DIAGNOSIS ?

A 45 years old male presented with anaemia and
massive splenomegly (upto umbillicus).
Blood Pictures:
 Hb% : 10gm%
 TLC : 150,000/cmm
 DLC:
 Myeloblast: 3%
 Promyelocytes: 3%
 Metamyelocytes: 16%
 Myelocytes: 30%
 Mature Neutrophils: 37%
 Basophils: 6%
 Lymphocytes: 5%

Red cells are Normocytic , Normochromic with occasional normoblast

 Reticulocytes: 4%
 Platelets: 4.5 lacks/cmm

GIVE YOUR DIAGNOSIS ?

A 60-year old male presentented with
 Aneamia, fever, hepatosplenomegaly.

Laboratory Investigations
 Haemoglobin :4.5 g/dl
 TLC : 30 x 103 /µL
 RBC count : 2.2 x 106 /µL
 MCV : 94 fL
 MCH : 31 pg
 MCHC : 33g/dl
 Platelet count: 20 X 103 /µL
 Total nucleated cell count of peripheral blood :
Myeloblast 44 N 26 L20 Nucleated RBC10

Bone Marrow Aspirate

 Hypercellular, M:E ratio: 1:2
 Eryhropoiesis: Megalolastic ,features of dyserythropoiesis present.
 Myelopoiesis: Blasts- 25%. Rest of the cells are normal.
 Megakaryocyte seen occasionally.

Peripheral Blood & Bone Marrow Aspirate Smears.

Questions:
 Give your diagnosis?
 Give points in favour of your diagnosis?
A fourteen years old boy presented with discharge from
right ear for last one year. High grade fever and vomitting
for last two days.
His C.S.F examinations revealed following abnormalities:
1. Colour and transparency : Turbid – dirty white
2. Sugar : 10mg/100 ml
3. Protein: 120 mg/100 ml
4. Chloride : 600mg/ 100 ml
5. Cells : 500 cells/ cmm (mostly polymorphs)

GIVE YOUR DIAGNOSIS ?

A 60 years male preseted with the history of increasing
weakness and fatiguability and generalized Lymphadnopathy.
Blood Pictures:
 TLC : 100,000/cmm
 HB% : 11%
 DLC
 Mature lymphocytes – 90% (caintains small and large lymphocyte
with few ‘baket cells’ are seen)
 Polymorphs – 10%
 Red cells shows slight hypochromia with occasional normoblasts.
 Platelets : 1.5 lacs/cmm

GIVE YOUR DIAGNOSIS ?

A 4-year old boy presented with
 Anaemia , fever , bony & joint pains
 Bleeding from nose & ecchymotic patches on the limbs
 Cervical Lymphadenopathy
 Hepatospleomegaly

LABORATORY INVESTIGATIONS:
 Haemoglobin: 5.2 g/dL
 TLC :70 X 103 /µL
 Platelet Count : 43 X 103 /µL
 DLC : Lymphoblasts 75 L20 N5
 Bone marrow: Hypercellular ,full of small homogeneous blasts cells.
 Sudan black & Myeloperoxidase staining of the blast cells: Negative
 Immunophenotyping: CD10 (CALLA), CD19 , CD20, & CD79a positive
 Cytogenetic Study: Hyperdiploidy (>50 chromosomes/cells), t(12:21) positive

BONE MARROW ASPIRATE SMEAR

QUESTIONS:

 What is your diagnosis?

 Give points in favour of your diagnosis ?
A 22-year old male presented with
 Anaemia
 Fever
 Petechial haemorrhages

Laboratory Investigations
 Haemoglobin: 4.5g/dL
 TLC : 75 X 103 /µL
 Platelet count :185 X 103 /µL
 DLC:
 Blasts: 42%
 Neutrophils: 36%
 Lymphocytes: 22%
 Sudan Black B & Myeloperoxidase staining of the blast cells: Negative
 Immunophenotyping: Blasts cells are CD41 & CD61 positive.
 Platelate Peroxidase : positive

Bone Marrow Aspirate Smears

Questions
 Give your diagnosis ?
 Give points in favour of your diagnosis?
A 30-years male presented with the history of fever
,fatiguability, weight loss haemorhagic manifestation and
splenomegly (4 cms).
Blood Picture:
 Hb% - 7.0 gms
 T.L.C -40,000/cmm
 D.L.C –
 Myeloblast-- 45%
 Myelocytes – 15%
 Metamyelocytes – 5%
 Promyelocytes—15%
 Neutrophils- 15%
 Lymphocytes-5%
Some of the blast cells contain auer Rods in their cytoplasm.
R.B.C are normocytic , hypochromic with anisocytosis.
Poikeiocytsis and occasional neucleated red cells.
 Platelets – 50,000/cmm

GIVE YOUR DIAGNOSIS ?

A 44-year old male presented with
 Anaemia
 Fever
 Bleeding gums
 Hepatosplenomegly

Laboratory Investigations.
 Haemoglobin: 4.5g/ dL
 TLC: 60 X 103/µL
 DLC:
 Monoblasts: 50%
 Neutrophils: 28%
 Lymphocytes : 22%
 Platelet count: 30 X 103 /µL
 Sudan Black B & Myeloperoxidase staining of blast cells: Negative
 Non specific esterase staining of the blast cells: Positive

Peripheral Blood & Bone Marrow Aspirate Smears

Questions:
 Give your diagnosis?
 Give points in favour of your diagnosis?