Compared to typical myeloblasts (as shown in the figure below), blasts have little cytoplasm and less fine and loose chromatin, which to some extent affected the binding of nucleic acid fluorescent dyes, leading to relatively weak FL signals of the corresponding particles in led the DIFF. scattering gram. In the last examination, a large number of myeloblasts and immature granulocytes proliferated and were released, making the DIFF scattergram more distinct features.
Clinical information
Alarm
DIFF
CBC resultsCase 02
Acute promelocytic leukemia (APL)
Peripheral blood morphology examination
Other examinations
Case analysis
The scattergram showed that the reduced WBCs were mainly particles in the range of monocytes and abnormal cells. Its morphological features correspond to those of acute promyelocytic leukemia (M3 subtype) in the FAB classification scheme.
Discussion
Because abnormal cells have fewer granules and a higher content of intracellular nucleic acid material, they usually fall in the Mon region of the DIFF distribution, leading to a false increase in Mon. Granules in the cytoplasm of abnormal promyelocytes contain a large amount of procoagulant enzymes, often causing patients to develop DIC.
CBC results
Acute myeloblastic leukemia with maturation (M2)
Bone marrow cytology examination
Acute myelomonocytic leukemia (AMML)
Acute granulocytic leukemia (M4) is classified into four subtypes (according to Chinese classification criteria), of which M4b is characterized by hyperplasia of monoblasts and promonocytes, with myeloblasts and promyelocytes accounting for > 20%. Flow cytometry. A cluster of abnormal myeloid blasts was observed, representing 26.04% of nucleated cells, which was consistent with the phenotype of AML chromosome 46,XX,t(6:9)(p23;q34.1)[20]]. abnormal granulocytic hyperplasia; granulocytes were seen at all stages of maturation, with myeloblasts accounting for 27%, mainly intermediate and late granulocytes.
The patient was a 64-year-old man who experienced recurrent chest tightness and dizziness for 20 days, and fever for 5 days.
Thrombotic thrombocytopenic purpura (TTP)
Due to the failure to diagnose thrombotic thrombocytopenic purpura (TTP) and start the relevant treatment in a timely manner, the patient's condition gradually worsened. Patients with thrombotic thrombocytopenic purpura (TTP) suffer from thrombocytopenia and significant anemia due to loose platelets or fibrin deposition in multiple small blood vessels, causing damage to passing platelets and RBCs. Decreased ADAMTS13 activity leads to the accumulation of larger vWF aggregates in endothelial cells, forming many platelet-vWF thrombi that consume platelets, resulting in thrombocytopenia.
WBC increased, mainly Ma; Neu#, Lym# and Mon# increased; severe anemia; PLT decreased; IPF and IRF increased The boundaries of each particle cluster in the Diff scattergram were clear, and particles in the Mon region were significantly dense and elongated in the high-fluorescence direction, suggesting the possible presence of myeloblasts and.
Clinical informationCase 06
Clustering of Neu particles also extended upward in a higher region, suggesting the presence of myelocytes and metamyelocytes.
Chronic myelomonocytic leukemia (CMML)
Chronic myelomonocytic leukemia (CMML) was previously considered a subtype of myelodysplastic syndrome (MDS) because of its myelodysplastic and myeloproliferative features. The patient in this case had splenomegaly, markedly elevated peripheral blood WBC, and increased monocytes. The patient was a 55-year-old female who was admitted with a history of "diagnosed with systemic lupus erythematosus for 16 years and found to have decreased platelets for more than 1 month."
In the WNB scattergram, a large number of pink particles are visible in the NRBC region.
CBC resultsCase 07
She had visited the hospital 1 month ago for systemic lupus erythematosus and was found to have decreased PLT and moderate anemia.
MDS with single lineage dysplasia (MDS-SLD)
In the acidic environment of the splenic sinus, RBC destruction is more than three times greater in the spleen than elsewhere due to a lack of glucose, a decrease in available ATP, and a further increase in cellular permeability. to sodium. The presence of gray-white particles in the DIFF distribution was mainly due to the extension of the Neu cluster towards the upper left corner. Dense particles in the Mon region led to ill-defined boundaries between Lym and Mon particle clusters, suggesting the possible presence of immature granulocytes, particularly promyelocytes and blasts.
The patient, an 80-year-old woman, was admitted to hospital in early August with dizziness and anemia.
CBC resultsCase 08
MDS with excess blasts (MDS-EB)
Immature granulocytes accounted for 16.9%, of which promyelocytes accounted for 3.4%, with large, round or oval cell bodies; nuclei deviated to one side; chromatins were rougher than those of blasts; the nuclei had begun to close and were less prominent than those of the explosions; the cytoplasm was blue, with varying numbers of purple-red granules with different morphologies and uneven distribution. Myeloblasts and promyelocytes constituted 18.4%, with large oval cell bodies and blue cytoplasm without granules; chromatins were good; 2-3 nucleoli could be seen.
Myeloblasts and promyelocytesPromyelocytes
Abnormal distribution of Lym and Mon particle clusters was observed in the DIFF scattergram, with Lym particles extending to the upper right and Mon particles distributed in the high fluorescence region shifted to the right.
Multiple myeloma (MM)
Due to the massive secretion and deposition of monoclonal antibodies on the bone marrow stroma, osteoclasts are activated, leading to bone disease and hypercalcemia. Patients with MM are prone to rouleaux formation of erythrocytes due to increased fibrinogen and globulin in the blood, which protect the surface potential of erythrocytes and weaken the mutual repulsion of erythrocytes. The patient was a 7-year-old male who was admitted to the hospital with intermittent back pain of more than two months' duration, together with pain in the chest and both lower extremities of more than one month's duration.
In the DIFF distribution, the Eos particles were clearly dense and the cluster of Lym particles lay in the region of high fluorescence.
Clinical informationCase 10
Immunophenotyping suggested B-cell acute lymphocytic leukemia, with a high probability of common B-ALL lymphocytes accounted for 97.5%, of which myeloblasts and promyelocytes accounted for 97%. The patient was a 48-year-old woman who had suffered from flatulent shortness of breath and low-grade fever without apparent cause for more than 10 days. Myeloblasts and promyelocytes accounted for 74.6%, with variable cell sizes, scant cytoplasm, verrucous processes, round or oval nuclei, fine chromatins, and visible nucleoli.
The patient was a 64-year-old woman diagnosed with chronic lymphocytic leukemia more than 2 years ago.
Clinical informationCase 12
Since the patient had no indication for treatment, CBC and blood smear examinations were routinely performed at the Department of Hematology.
Chronic Lymophocytic leukemia (CLL)
The percentage of neutrophils is decreased and thrombocytopenia and/or anemia may occur as the disease progresses. Evidence of progressive bone marrow failure: manifested as progressive reduction in hemoglobin and/or platelets, with a hemoglobin level of less than 100 g/l and platelets less than L. The patient was a 60-year-old man who presented with pain in the left knee joint and limited mobility for more than 2 years, which worsened over the past 3 months.
There was mild deformity in the left knee joint, and the patient was admitted to hospital for "left knee osteoarthritis".
Mantle cell lymphoma (MCL)
Mantle cell lymphoma (MCL) is a small-to-medium-sized, monomorphic, mature B-cell tumor with specific immunophenotype and reproducible genetic abnormalities. The clinical manifestations of MCL are nonspecific, so the diagnosis and prognosis evaluation at the initial visit are critical. HemaCase—Clinical Case Booklet | 36 Mantle cell lymphoma (MCL) is a small- to medium-sized, monomorphic, mature B-cell tumor with specific immunophenotype and reproducible genetic abnormalities.
The patient was a 31-year-old woman admitted in November due to weeks of gestation with ultrasound indicating oligohydramnios."
CBC resultsCase 14
It was speculated that PLT-I was falsely low due to interference from large platelets or platelet aggregation.
May-Hegglin anomaly
The patient had thrombocytopenia, giant platelets, and neutrophilic inclusions consistent with manifestations of May-Hegglin anomaly. Despite the decrease in the number of platelets, the total volume of platelets in the blood does not significantly decrease due to the increase in platelet size. Because of significant thrombocytopenia, most patients are misdiagnosed with ITP at initial diagnosis and undergo unnecessary hormone therapy or splenectomy.
In addition, giant and large platelets were observed in 59/100 WBCs, and the PLT estimate was consistent with the PLT-O result.
CBC resultsCase 15
Pelger–Huët
H anomaly
Thus, a clinical consultation was conducted and the patient was advised to undergo an analysis of the immediate family pedigree. The next day, CBC samples were taken from the patient's son and daughter for testing and the results were normal. The above results showed that the peripheral blood neutrophil morphology of the patient's son and daughter was generally the same as that of the patient, and the neutrophil nuclei were mostly rod-shaped or bilobed.
The patient was a 52-year-old woman who had pyrexia, diarrhea, headache, fatigue, and nausea a week ago.
Green neutrophilic inclusions
Neutrophils exhibited vacuolar degeneration and demonstrated bacterial phagocytosis along with the presence of blue-green round inclusions in both neutrophils and eosinophils. After the discovery of blue-green inclusions, high-sensitivity cardiac troponin I (hs-cTnI), alanine aminotransferase, WBCs, and other test indicators continued to rise or remained at high levels, and the NRBC percentage was as high as 20%. Blue-green inclusions are pale green inclusions that appear in the cytoplasm of neutrophils or monocytes and are usually associated with acute liver failure, lactic acidosis, and other diseases.
Their appearance indicates that the patient is in a critical condition, which can alert clinics to closely monitor the patient's emergency condition, actively treat the underlying disease, protect the liver and correct lactic acidosis in time.
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2.中国抗癌协会血液肿瘤专业委员会、中华医学会肿瘤学分会、中国国际医疗保健交流促进会肿瘤分会套细胞淋巴瘤诊断3.中国肿瘤学会血液学肿瘤专业委员会，会议中华医学会血液学分会中国慢性淋巴细胞白血病工作组.中国慢性淋巴细胞白血病/小淋巴细胞白血病。成人 AML 的诊断和治疗：代表 ELN 的国际专家小组的 2022 年建议[J].
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