Hematology Case 66
Patient Data
Male patient 38 year old.
Clinical Data
Presented to E.R. with epigastric pain.
Intermittent vomiting & constipation started 2 weeks ago.
O/E.: Pallor & mild epigastric tenderness.
Abdominal U.S.: Mild fatty liver. No splenomegaly or lymphadenopathy.
Related Laboratory Results
CBC:
- WBC: 16.5x103 /uL (Neutrophils: 0.3x103 /uL - Lymphocytes: 6.6x103 /uL - Monocytes: 9.5x103 /uL - Eosinophils: 0.05x103 /uL - Basophils: 0.02x103 /uL) "Cell counter Diff. count".
- HGB: 6.3g/dL - MCV: 105fL -MCH: 31pG - MCHC: 30% - Reticulocytic count%: 4.1% (R.R.: 0.5-2) - Absolute Reticulocytic count: 82 x109 /uL (R.R.: 50-100)
- Platelet: 109x103 /uL
R.F.T.: Normal
LDH: 364 u/L (R.R.: 98-192).
Amylase: 45 u/L (R.R.: 25-115)
Peripheral Smear & immunophenotyping : See below.
Case Picture(s) / Photo(s)
Images Comment / Findings:
Peripheral Blood Smear:
Severe macrocytic anemia. RBCs show polychromasia , anisocytosis & poikilocytosis.
Mild thrombocytopenia.
Mild leukocytosis : with the following manual/microscopic differential count: Blast cells: 69% - Abnormal mononuclear cells: 6% - Lymphocytes: 21% - Monocytes: 1% - Neutrophils: 3%.
Blast cells : 69%. They are medium sized with high nuclear cytoplasmic ratio. Cytoplasm is basophilic sometimes granular. Auer rods are seen in few of them. Nucleus has fine chromatin with 1 to 3 nucleoli.
Immunophenotyping :
Sample: Peripheral Blood
Gating: SSC/CD45(dim)
Positive markers: CD45(dim), CD34, HLA-DR , cMPO, CD13 (dim), CD33, CD64(dim), CD38, CD7 (dim).
Negative markers: CD19, cCD79a, cCD3, CD3, CD5, CD2, CD4, CD8, CD11b, CD56, CD14, CD16, CD20, and CD22.
Comment: The gated blast cells using SSC/CD45 dim gating strategy is 73%. They express immunophenotype of Acute Myeloid leukemia with aberrant CD7 expression.
Final Diagnosis
A case of acute myeloid leukemia for cytogenetic workup.
Patient signed LAMA consent (Leave against medical advice). Patient left the hospital refusing referral to specialized center.
Additional Note
Most of cell counter analyzers count myeloblasts as monocyte. Peripheral blood smear is recommended for cases of monocytosis.
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