Acute Leukemia

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

Microscopic Objective: 50x

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

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