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WBC Disorders

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Interactive Case Study

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AmirReza Dehghanian M.D.APCP

Assistant Professor of Surgical and Clinical Pathology

Department of Pathology and Laboratory Medicine

Shiraz Medical School

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A 35 year- old male referred to the physician with chief complaint of lateral neck mass since two months ago

He also complains of pruritus and night sweat and fever

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  • P/E :vital signs are normal except for body temp: 38°C, Several enlarged non-tender, firm and immobile nodes are felt in both sides of neck and in axillary region. On palpation liver and spleen are not enlarged
  • 1. What is your differential diagnosis ?
  • 2. Do you order any lab test ?
  • 3. What will be your next plan ?

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History and Physical Examination Clues to Diagnosis with a Neck Mass�

Finding

Diagnosis

History

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Fevers, pain

Inflammatory

Present at birth

Developmental

Rapidly growing mass

Inflammatory, malignancy

Physical examination

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Hard, irregular, firm, immobile

Malignancy

Larger than 2 cm

Malignancy

Midline location

Thyroglossal duct cyst, dermoid cyst, thyroid mass

Shotty lymphadenopathy

Reactive lymph nodes

Supraclavicular location

Malignancy

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List of Diff. DX

  • Metastatic:
      • Squamous cell carcinoma (SCC)
      • Papillary Thyroid Carcinoma
      • Adenocarcinoma (most commonly from salivary gland origin)
      • All other primary sites imaginable have been reported.
  • Primary neck tumors:
      • Thyroid
      • Lymphoma
      • Salivary gland neoplasia
      • Paraganglioma

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  • Congenital:
      • Thyroglossal duct cyst
      • Branchial cleft cyst
      • Hemangioma
      • Dermoid cyst
      • Ectopic thyroid
      • Thymic cyst
  • Inflammatory:
      • Lymphadenopathy (may be viral or bacterial)
      • Sarcoid
      • Tuberculosis
      • Cat scratch
      • Sialadenitis

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Location

Diagnosis according to site and nature

Developmental

Inflammatory/reactive

Neoplastic

Anterior sternocleidomastoid

Branchial cleft cyst,* vascular malformation

Reactive lymphadenopathy,* lymphadenitis (viral, bacterial),* sternocleidomastoid tumor of infancy

Lymphoma

Midline

Thyroglossal duct cyst,* dermoid cyst*

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Thyroid tumor

Occipital

Vascular malformation

Reactive lymphadenopathy,* lymphadenitis*

Metastatic lesion

Preauricular

Hemangioma, vascular malformation, type I branchial cleft cyst

Reactive lymphadenopathy,* lymphadenitis,* parotitis,* atypical mycobacterium

Pilomatrixoma, salivary gland tumor

Submandibular

Branchial cleft cyst,* vascular malformation

Reactive lymphadenopathy,* lymphadenitis,* atypical mycobacterium

Salivary gland tumor

Submental

Thyroglossal duct cyst,* dermoid cyst*

Reactive lymphadenopathy,* lymphadenitis (viral, bacterial)*

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Diagnostic Procedures

  • Fine Needle Aspiration and biopsy (FNA)
  • Tru-cut Biopsy
  • Incisional Biopsy
  • Excisional Biopsy

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Trucut biopsy

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  • Lymph node biopsy shows total effacement of nodal architecture and infiltration of lymph node by a heterogeneous population of cells composed of lymphocytes, histiocytes, plasma cells and eosinophils
  • There is many atypical large cells
  • Some cells show eosinophilic cytoplasm with binucleated large nuclei and a central prominent nucleoli

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  • What is your diagnosis?
  • What is the diagnostic clue for this disease histologically?
  • Describe other subtypes of this disorder?

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  • The patient underwent abdominal surgery and staging splenectomy was done since it show focal whitish areas. Bone marrow biopsy is normal. Liver wedge resection is normal. Single paraaortic abdominal lymph node was enlarged and histologically was positive.
  • What is the stage of disease?
  • What do you know about the etiology?
  • Do you know about immunohistochemical (IHC) markers?

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  • 1-Nodular Sclerosis
  • 2-Mixed Cellularity
  • 3-Lymphocyte Predominance
  • 4-Lymphocyte Rich
  • 5-Lymphocyte Depletion

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Myeloid Disorders

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  • A 30 year old male referred to a physician with chief complaint of fever, easy fatiguability & pallor for one month duration.
  • P/E revealed a pale, acutely ill thin male with vital signs of BP: 100/60, Temp: 39.5, RR- 24, PR: 100.
  • 1. What is your differential diagnosis ?
  • 2. What is your first plan?

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  • CBC showed HB: 9 gm/dt, WBC count : 14000/ml, platelet count: 20000/ml , WBC diff: Blast: 75% lymphocyte: 20%, Monocyte: 5%

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  • 3. What test should be recommended to confirm the diagnosis:

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  • Bone marrow aspirate showed: 90% blasts having central nuclei, fine chromatin with three to five nucleoli, Some of the blasts have azurophilic granules in their cytoplasm.

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  • 4.What do you know about the classification of this disorder?

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Lymphoblast

Myeloblast

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Auer Rod

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