Prof. Salma Afrose

Drop of Blood – Unravels Mysteries Prof. Salma Afrose Department of Hematology Dhaka Medical College Peripheral Blood Film (PBF) PBF is a laboratory workup that involves cytology of Peripheral blood cell smear on a slide Clinical history Physical examination Lab investigation Diagnosis Importance of PBF Basic & highly informative hematological tool for • Screening • Diagnosis • Monitoring disease progression & • Therapeutic response So for successful clinical practice understanding interpretation of PBF is essential Indication • Clinical request from attending clinician (based on clinical suspicion) • Sometimes from laboratory due to abnormal finding on an automated counter • Unexplained cytopenia • Unexplained leukocytosis, lymphocytosis, monocytosis • Unexplained hemolysis or jaundice • Sepsis • Liver failure • Hematological malignancies • Severe bacterial sepsis • Parasitic infection • Anemia evaluation Clinical indications for examination of PBF • Features suggestive of anemia, unexplained jaundice, or both • Features suggestive of sickle cell disease – dactylitis or sudden splenic enlargement and pallor in a young child or, in an older child or adult, limb, abdominal, or chest pain • Features suggestive of thrombocytopenia (e.g. petechiae or abnormal bruising) or neutropenia (e.g. unexpected or sever infection) • Features suggestive of a lymphoma or other lymphoproliferative disorder – lymphadenopathy, splenomegaly, enlargement of the thymus (a mediastinal mass on radiology) or other lymphoid organs, skin lesions suggestive of infiltration, bone pain, and systemic symptoms such as fever, sweating, itching and weight loss • Features suggestive of a myeloproliferative disease – splenomegaly, plethora, itching or weight loss Clinical indications for examination of PBF (contd.) • Suspicion of disseminated intravascular coagulation • Acute or recent-onset renal failure or unexplained renal enlargement, particularly in a child • On retinal examination, hemorrhages, exudates, signs of hyperviscosity, or optic atrophy • Suspicion of a bacterial or parasitic disease that can be diagnosed from a blood smear • Features suggestive of disseminated nonhematopoietic cancer – weight loss, malaise, bone pain • General ill health, often with malaise or fever, suggesting infectious mononucleosis or other viral infection or inflammatory or malignant disease Interpretation Key Features in the blood film Red cells Size Microcytes, normal sized cells, macrocytes (a lymphocyte or segmented neutrophil can be employed for reference) anisocytosis Shape Variation from the normal round profile, for example oval, pencil, tear-drop, sickle, fragmented, crenated, burr cells and acanthocytes; poikilocytosis. Abnormality of overall configuration, for example spherocytes, target cells, stomatocytes Pattern of Normal intensity of hemoglobin staining, or subnormal hypochromatic cells with staining characteristically increased central pallor. Increased purple hue in polychromatic cells Inclusions Basophillic stippling, Howell_Jolly bodies, malarial parasites, Pappenheimer bodies, areas of deficient staining referred to as blisters. Association Clumping of red cells to form aggregates or rouleaux Abnormal cells Presence of erythroblasts Interpretation (contd.) Key Features in the blood film White Cells Relative number Decreased, normal or increased Morphology Lymphocytes, monocytes, and segmented granulocytes present in normal or abnormal ratios. Presence of cells normally absent, for example immature myeloid or lymphoid cells, atypical lymphocytes, hypersegmented neutrophils, or increased proportions of band neutrophils Platelets Relative number Decreased, normal or increased Morphology Normal or enlarged forms Red blood cells • Automated cell counter & histogram gives information about anemia • But morphologic abnormalities can only be determined by blood film • Variation in cell shape • Red cell inclusion Disorder associated with common red cell poikilocyte Name Characteristics Also seen in Spherocytes HS, IHA Wilson disease, HA, Hb CC disease Elliptocyte HE IDA, MDS, Thallassemia, Megaloblastic anemia Tear drop cell HPP, HE Severe iron deficiency, Thallassemia, MDS, myelofibrosis Schistocyte MAHA, fragmentation hemolytic anemia Echinocyte Renal failure, malnutrition Acanthocyte Anemia in liver disease, a betalipoproteinemia Splenectomy Target cell Cholelithiasis, Hemoglobin C, liver disease Iron deficiency, Thallassemia Stomatocyte Hereditary stomatocytosis Alcoholism Hemolytic Anemia • HE • South East Asian Ovalocytosis • Spherocytosis (D/D) • Microspherocyte (burn & MAHA) MAHA • TTP & HUS • DIC • Acute hemolysis by oxidant drug • 6GPD deficiency • Wilson disease -Bite cell • CHAD Macrocytic anemia Essential for differential diagnosis (PBF) • megaloblastic anemia – Ovalomacrocytosis with hypersegmentation of neutrophil • Liver disease – Round macrocyte, target cell, no hyper segmented neutrophil • MDS – Macrocytosis, dysplastic neutrophil, giant or hypo granular platelet • CDA – Macrocytosis with Poikilocytosis • Hemolysis , Recent blood loss – Macrocytosis with Polychromasia Microcytic Anemia Red cell indices & biochemical tests help in diagnosis of majority cases but film is essential to identify • Pappenheimer body & • Basophilic stipling in sideroblastic anemia & lead poisoning Hemoglobinopathy & Thalassemia Needed for diagnosis & D/D • Sickle cell disease – Rapid diagnosis • Thalassemia – diagnosis & status of spleen NRBC Signifies bone marrow damage or stress in some cases serious underlying disease • Hemolytic anemia • Megaloblastic anemia • Myloproliferative disorder • Multiple myloma • After splenectomy • Storage disease • Thalassemia major • MDS • Sarcoidosis • Sepsis • Effective erythropoiesis - Reticulocytosis , polychromasia, immature granulocyte • Ineffective erythropoiesis – NRBC without reticulocytosis • Red cell agglutination – presence of antibody • Rouleaux formation • Multiple myloma • Leishmaniasis • Severe infection White Blood Cell • Morphology, distribution, granularity, nuclear configuration • Leukocytosis • Bacterial infection • Inflammation • Malignancy • Tissue injury • Steroid • Myloproliferative disorder • Hyposegmented in – sepsis, MDS • Hyperlobated in – B12 Folic Acid, MDS, drugs • Toxic granulation in – infection Direct diagnosis from PBF • APL • AML • Hairy cell leukemia • ALL • Burkitt lymphoma • SLVL Platelet Platelet distribution & morphology seen Thrombocytopenia • PBF essential for 2 purposes – • Confirm thrombocytopenia – small clot, clumping & platelet satellitism • Look for underlying cause • Morphology small platelet in Aplastic anemia • Giant platelet – Immun thrombocytopenia, hypersplenism • Giant platelet with red cell fragment and helmet cell – MAHA Thrombocytosis • Microcytic hypochromic reactive • Platelet anisocytosis with baseophilia myloproliferative Parasites • Malaria • Leishmania • Filaria Serendipity Fortuitous investigation that may be of diagnostic importance • Red cell fragmentation • Hyposplenism • Cryglobenemia (hepatitis C infection) • Red cell agglutination (LPD, IM) • Dysplastic feature typical of HIV • Malaria, leishmaniasis, filariasis • Fungal infection • Candidiasis • Histoplasmosis • Bacteria Pneumococcal infection Case 1 • A 10 year old boy treated as ITP for last 7 yrs – a case of BSS • Being large platelet – Count is low in automated analyser Case 2 • A 45 yr old lady have been suffering from fever for last 1 yr. Her CBC shows Neutrophil leukocytosis with Monocytosis • Having multiple antibiotic culture of blood, C/S even TB drugs • Blood film shows CMML as Analyser can not identify some monocyte & dysplasia Case 3 • A middle aged man suffering from leg oedema normocytic anemia but no cause is found • PBF when properly seen shows thick target cell with normocytic anemia • CLD with Hepatitis C positivity Case 4 • A patient presented with thrombocytopenia & diagnosed as ITP. He is not responding to drugs. Going before second line drug his PBF is checked & found to have Malaria • Treatment of Malaria cure him of thrombocytopenia Despite major advances in hematology automation, genetic & molecular techniques in diagnosis of various diseases, PBF remains a frontline diagnostic tool for unraveling mysteries behind cryptic symptoms & signs Thank you .

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