Hematology Case 55

Presented By Dr Mohammad Moharram - Dr Galal Bashanfer

Released on 7-5-2021

Patient Data

51 year old male.

Clinical Data

History: A known case of ischemic heart disease (Inferior MI since 2012)

Complain: Dyspnea and abdominal distention.

Examination: Massive unilateral Rt. side pleural effusion. Diminished air entry on both sides markedly on right. Moderate ascites.

Radiological: CT abdomen is highly suggestive of peritoneal metastasis. ?? Omental cake and cecal mass.

Related Laboratory Results

  • CBC: - WBC: 6.2x103 /uL - HGB: 8.2 g/dL - MCV: 95fL -MCH: 27.5 pG - Platelet: 65x103 /uL

  • AST: 60 u/L (R.R.: 15-41) - ALT: 23 u/L (R.R.: 17-63) - ALP: 44 u/L (R.R.:30-91) - ALB: 34 g/L (R.R.: 35-50).

  • BUN: 29.4 mmol/L (R.R.: 2.5-6.4) - Creatinine: 186 umol/L (R.R.: 55-113).

  • Na: 164 mmol/L (R.R.: 135-144) - K: 3.6 mmol/L (R.R.: 3.5-5.1) - Ca: 3.1mmol/L (R.R.: 2.2-2.5).

  • Pleural Fluid aspirate was sent to the lab for cytological count , differential count and cytopathological evaluation (See below)

Provisional Diagnosis

Malignant secondaries of unknown primary

Case Picture(s) / Photo(s)

Pleural Fluid - Giemsa Stain

Pleural Fluid - Giemsa Stain

Pleural Fluid - H & E

Pleural Fluid - Immunocytochemistry

Images Comment / Findings

  • Cytological count and morphology:

Total cell count: 7.5xx103 /uL

Mononuclear cells are the predominant cells. The mononuclear cells are moderate to large sized cells with Basophilic and Vacuolated cytoplasm. Their nuclei are mostly of fine chromatin with 1 to 3 nucleoli commonly seen.

Immunophenotyping for pleural fluid is recommended.

  • Cytopathological Examination : (H.&E. and immunocytochemistry):

Smear show numerous atypical large non-cohesive cells.

These cells are positive for : LCA, PAX5, CD79a, BCL2

& are negative for BER-EP4, CD138, CD10, C-kit.

Remnant T lymphocytes are positive for CD3.

Final Diagnosis

Pleural fluid features are consistent with non-Hodgkin lymphoma , B-cell type.

Lymph node biopsy or primary mass biopsy is recommended for definite diagnosis.

Additional Note

Patient died 5 days later. Final diagnosis was not reached.