11 Sep MEDT 4600 Hematology Review

History: A 6-year-old male is admitted to the hospital for a work up for juvenile-on-set

diabetes mellitus. He was also being treated for a macrocytic anemia.

Lab results were:

WBC 2.9 (x10 9 /L)

RBC 2.53 (x10 12

/L) HGB 10.2 (g/dL)

HCT 29.3 (%)

MCV 116.0 fL

MCH 40.6 (pg)

MCHC 34.2 (%)

RDW 18.1 (%)

PLT 76 (x10 9 /L)

Retic 0.4%

Question 1 – What is the most likely diagnosis based on the lab results above?

Additional testing:

Bone Marrow:

Decreased M:E ratio

3% Blasts

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Peripheral Blood Smear:

Macrocytic RBCs

Low platelet count

Hyposegmented neutrophils

Treatment

Patient was given vitamin B12 for 6 weeks– no change in the anemia status (patient did not

respond to treatment)

Question 2 – Does our patient have megaloblastic anemia? Why or why not?

Question 3 – Looking at ALL the lab results again, what is another possible diagnosis for this

patient?

Patient Outcome

Patient was given supportive therapy for 4 years (packed red blood cells and platelets). Patient

died of overwhelming infections

Case Study B

History: A 44-year-old male was first seen in the VA hospital and then transferred to the city’s

larger hospital for re-evaluation. He was not responding to treatment that was prescribed.

Lab results were:

WBC 122.2

RBC 2.48

HGB 8.2

HCT 26.0

MCV 90.7

MCH 32.9

MCHC 36.3

RDW 14.3

PLT 27

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Coagulation:

Fibrinogen 67 mg/dl

PT 19.3 sec

INR 2.0

PTT 39.5 sec

FSP >40 µg/dl

D-dimer 4250 NG/ML

Question 1 – What do the above lab results indicate?

Additional testing

Peripheral Blood Smear Day 1:

Several large WBCs with a large amount of nucleus, bi-lobed nucleus and hypogranular.

These cells were reported as monocytes (monocytosis)

Peripheral Blood Smear Day 2:

On this day the MT performing the differential called the abnormal WBCs hypogranular

promyelocytes.

Question 2 – Based on the additional testing from Day 1, what is the best possible diagnosis?

Yet the results were different on Day 2, what is the best possible diagnosis based on the

peripheral blood smear results from Day 2?

Patient Outcome

Patient died about 3 months later

Case Study C

History: A 4-year-old male presents to his local pediatrician with irritability, loss of appetite

and a distended abdomen. (Patient has a twin brother who is healthy and has not previous

history of illness.) On physical exam the patient was febrile and irritable. The spleen was

massively enlarged, liver was normal size and there was not lymphadenopathy.

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Lab results were:

WBC 298.9

RBC 3.38

HGB 11.0

HCT 33.0

MCV 85.6

MCH 30.6

MCHC 33.2

RDW 17.4

PLT 366

Retic 1.4%

LAP Score: 6

Philadelphia chromosome: Negative

Bone Marrow:

Hypercellular marrow

Peripheral Blood Smear:

All immature stages seen including bands, myelocytes, metamyelocytes,

promyelocytes, blasts. Absolute monocytosis was aboserved .

Kleihaur-Betke stain indicated that roughly 45% of RBCs contained HbF. Question 1 – What is the best diagnosis based on all the lab results? (Be specific this is a

subgroup disease.)

Patient Outcome

Patient did not respond to treatment. Patient died and four months later his brother was

diagnosed with the same disease.

Case Study D

History: A retired seventy-year-old male while sailing around the world fell on his yacht.

When examined by a local hospital (in Brazil) a fractured hip and pneumonia were found. He

returned to the U.S. for a follow up.

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Lab results were:

WBC 5.7

RBC 2.83

HGB 9.0

HCT 27.0

MCV 95.5

MCH 31.9

MCHC 33.4

RDW 23.4

PLT 101

Peripheral Blood Smear:

28% plasma cells

Rouleaux was noted

Question 1 – What do the above lab results indicate?

Additional testing

Protein Electrophoresis:

Albumin 30.5%

Alpha 1 2.6%

Alpha 2 8.4%

Beta 5.9%

Gamma 53.6%

Question 2 – What results are abnormal in the protein electrophoresis testing?

Additional testing

Immunoglobulin Quantitation:

Result Reference

IgG 307 723-1,685 mg/dl

IgA 1069 69-382 mg/dl

IgM 31 63-277 mg/dl

Question 3 – What is the final diagnosis based on ALL of the lab results?

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Case Study E

History: A 53-year-old male developed flu like symptoms with a high fever that progressed

over the course of the week. Other symptoms include a weakness in his arms and legs, joint

pains, painful headache and a sensitive scalp.

Lab results were:

WBC 3.7

RBC 3.45

HGB 11.0

HCT 34.0

MCV 89.5

MCH 29.7

MCHC 33.2

RDW 14.1

PLT 118

Differential:

Segs 72%

Lymphs 9%

Mono 19%

Retic 2.0%

*MT noticed erythrocyte intracellular ring-like structures.

Chemistry:

AST 4863

ALT 1855

ALP 72

Total Bilirubin 0.6

Direct Bilirubin 0.3

Total protein 6.0

Additional Information: Several of the rings like structures were extracellular and the patient

has never been outside of the U.S.

Question 1 – Based on all of the results and information, what is the best possible diagnosis?

And how was the patient most likely infected with this disease?