Hematology Interest Group

Case Study

June 11, 2017


Acute Leukemia10x.jpg

A 69-year-old female presented with fatigue, shortness of breath, bruising, dizziness, and weight loss.  The patient had no medical history on file. The patient had severe bruising that covered her entire body and looked malnourished; abuse and neglect were suspected during physical exam. The patient went into cardiac arrest several minutes after the physical exam was performed. Stat laboratory test were performed and 2 units of 0 negative RBC packed cells were released.  

Laboratory test indicated severe anemia, with a hemoglobin level of 4.4 gm/dL, leukocyte count of 29.9x103/uL (differential count: neutrophils 0%, Lymphocytes 16%, Monocytes 0%, Blast 82%, Bands 2%, NRBC 10%) and thrombocytopenia (4x103/uL).  Unfortunately the patient passed away before any immunophenotyping and/or cytogenetic tests were performed.

Laboratory Results

Hemogram  

Patient’s Results

Reference Range

Red Blood Cell Count (RBC)

1.42  x 10 x106/uL

3.8 – 5.1 x 10 x106/uL

Hemoglobin (HgB)

4.8 g/dL

12.0-15.6 g/ dL

Hematocrit (Hct)

15.4 %

35.7 - 445.9 %

Mean Corpuscular Volume (MCV)

110.7 fl

92.5 -99.8 fL

Heam Corpuscular Hemoglobin (MCH)

32.5  pg

27.0 - 34.3 pg

Mean Corpuscular Hemoglobin Concentration (MCHC)

29.8 g/dL

32.1 - 35.3 g/dL

Red Cell Distribution Width (RDW)

14.9 %

11.5 - 15.0 %

Platelets

4 x 103/uL

144 - 423 x 103/uL

White Blood Cell Count (WBC)

27.2 x 10 x103/uL

4.0 - 11.0 x 103/uL

DxH 800 Interpretation/Flags

According to the hospital laboratory protocol on slide criteria, a blood smear was prepared based on the following flags:

Suspect Flags         

Variant LY                

LY Blast        

        

                

The scatterplot shows marked populations in the LY Blast region. Suspect message LY Blast and in the lymphocyte area of the scattergram is a data pattern consistent with the possible presence of  blast.

Technologist - Manual Differential

Test

Patient’s Results

Reference Range

Neutrophils

1 %

0.3 x103/uL

50 – 70%

1.4-6.5 x103/uL

Lymphocytes

11 %

3.0 x103/uL

20 – 40%

1.2 - 3.4x103/uL

Monocytes

0 %

0.0 x103/uL

2-9%

0-0.7 x 103/uL

Eosinophils

0 %

0.0 x103/uL

0-4 %

0-0.5 x 103/uL

Basophils

0 %

0.0 x103/uL

0-2 %

0-0.2 x 103/uL

Other

88%

23.9x103/uL

0-8%

NRBC

11 /100 WBC

0 /100 WBC

Chemistry

Test

Patient’s Results

Reference Range

Sodium

135 mmol/L

136 – 145mmol/L

Potassium

5.6 mmol/L

3.5 – 5.0 mmol/L

Chloride

93 mmol/L

98 - 107 mmol/L

Total CO2

10 mmol/L

22 - 29 mmol/L

Calcium

9.3 mg/dL

8.8 – 10.2 mg/dL

Glucose

332 mg/dL

82- 100 mg/dL

Total Bilirubin

6.2 mg/dL

0.1 – 1.3 mg/dL

AST

361 IU/L

<= 40 IU/L

ALT

174 IU/L

<= 41 IU/L

ALK Phos

61 IU/L

35 – 104 IU/L

Lactic Acid

18.9 mmol/L

0.5 – 2.2 mmol/L

NT Pro-BNP

1730 pg/L

<= 319 pg/L

Note: An NT pro-BNP level less than 300 pg/mL in any patient, regardless of age. Effectively rules out acute CHF with a 99% negative predictive value.

Coagulation

Test

Patient’s Results

Reference Range

PT

17.1 second(s)

9.3-12.3 second(s)

INR

1.51

0.87-1.15

Test

Patient’s Results

Reference Range

PTT

41.7 second(s)

23.5-35.0 second(s)

Note: Therapeutic range for direct thrombin inhibitors: Argatroban is 1.5 to 3 times the aPTT baseline. Lepirudin is 1.5 to 2 times the aPTT baseline. The aPTT should not exceed 100 seconds.  The dosage of Argatroban should be decreased in patients with hepatic impairment.  The dosage of Lepirudin should be decreased in renal insufficiency. The aPTT is no longer the appropriate test to monitor unfractionated heparin anticoagulation.

Test

Patient’s Results

Reference Range

 D-Dimer

>5000    

< 230 ng/mL D-DU

Peripheral Blood Smear

40.jpg

Microscopic Objective: 50x

40x.jpg

Microscopic Objective: 50x

  

100x.jpg 100xx.jpg 1000.jpg   

            Microscopic Objective: 100x 

Hematology Interest Group

Pathology Report

Pathologist Interpretation

The red blood cells are macrocytic normochromic and markedly decreased in number.  No increased polychromasia or schistocytes are noted.  The white blood cells are increased in number and composed of 84% blasts and 17% lymphocytes.   The platelets are markedly decreased in number. Severe anemia, thrombocytopenia, and leukocytosis are noted.  84% circulating blasts with a very high nuclear to cytoplasmic ratio, fine chromatin pattern, and prominent nucleoli are noted.  The findings are consistent with acute leukemia.  Clinical correlation is recommended.

Diagnosis

Cardiopulmonary arrest, Anemia, unspecified type; Thrombocytopenia; Anoxic brain injury; death

References

  1. Beckman Coulter. (2013). Beckman Coulter. Retrieved July 1, 2017, from http://www.beckmancoulter.com/ucm/idc/groups/public/documents/webasset/glb_bci_152233.pdf
  2. Cleveland Clinic. (2014, April). Cleveland Clinical. Retrieved July 1, 2017, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/acute-myelogenous-leukemia/
  3. Keohane, Elaine. (2016). Rodak's Hematology Clinical Principles and Applications. St. Louis: Elsevier.

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