Hematology Case Studies using Digital Cell Image Analysis

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1 Hematology Case Studies using Digital Cell Image Analysis Carl Trippiedi Senior Product Manager Sysmex America, Inc. Goals for Today Obtain a working knowledge of digital cell image analysis. Learn briefly about how automated digital systems work. Obtain an understanding of some of the advantages of using automated cell image analysis in the clinical laboratory. Demonstrate how automated cell image analysis can provide better and more rapid diagnoses through the use of examples 1

Workloads Decreased Staffing Laboratory Trends Demand for

2 Laboratory Trends Reduction of Qualified Medical Technologists More Generalists Less Specialists Increased Workloads Decreased Staffing Laboratory Trends Demand for Accurate Results Demand for Shorter TAT Increased Capital Equipment cycles 2

3 Options To Manage The Slide Review Remains Significantly a Manual Process Concerns with Manual Microscopy Labor intensive Not standardized Challenging to train No historical images Limited consultation No traceability LIS 3

Why Automate the Manual Differential The need

Whole blood sample in lavender top tube 2.

4 Why Automate the Manual Differential The need for a greater level of standardization and consistency for the manual differential Increasing demand for connectivity between healthcare providers Location and Pre-Classification of WBCs 1. Whole blood sample in lavender top tube 2. ~ 20% tests flagged in cell counter 3. Peripheral blood smear 4. Barcode slides loaded on analyzer 5. Automatic location and pre-classification of cells performed by analyzer 8 4

5 How it Works Finding the WBC Monolayer Collecting Locations of WBCs Start scanning 10x images End Start Centre line Pre-Classification with help from the Neural Network ANN-based Classifier Feature Extraction Categories: shape, size, colour, texture, etc. LYM BAS 5

The RBC analysis WBC monolayer The RBC monolayer can be: Within the WBC monolayer Partly within the WBC monolayer Completely outside the WBC monolayer RBC Monolayer 11 The RBC analysis RBC

6 The RBC analysis WBC monolayer The RBC monolayer can be: Within the WBC monolayer Partly within the WBC monolayer Completely outside the WBC monolayer RBC Monolayer 11 The RBC analysis RBC monolayer is defined at 50x magification Separate RBC monofinder process The RBC monolayer is typically in a slightly thinner area od the smear ~ 35 images are acquired for the RBC precharacterization 12 6

7 Pre-Classified WBC s Presented on Screen One Click High Resolution Detail 7

8 Locate Abnormal Cells Faster Built In Cell Reference Library 8

9 RBC Characterization Standardize RBC Tools 9

10 Standardize Platelet Estimates Expand with Body Fluid Differentials 10

11 Network Connectivity Cell Image Analyzer Clinical Hematology RRS Pathology RRS Conference Room RRS Oncology 21 Network Connectivity Cell Image Analyzer Cell Image Analyzer Review Software Review Software Hospital A Hospital B 22 11

12 Benefits of Real Time Connectivity Clinicians access to images reduces TAT Easy saving/sharing of images Real-time collaboration images anywhere Access from home Unlimited image storage Maintain competency across multiple sites Centralize expertise Share staff Key Points Automated Digital Imaging systems are not just about pre-classification..they are about providing powerful tools that improve the speed and accuracy of the Technologist and the Lab. The Med Tech remains an integral and important part of the differential. 12

Cell Image Analysis Portfolio Introducing: DI-60 Cell Image Analyzer: Complete integration to the XN line or in configuration with an SP-10 called the Integrated Slide Processor (ISP) Targeted for

Analyzes both blood and body Fluid samples CellaVision DM96 Cell Image Analyzer : Medica EasyCell assistant, Cell Image Analyzer Provides automated assistance and standardized results for blood

13 Cell Image Analysis Portfolio Introducing: DI-60 Cell Image Analyzer: Complete integration to the XN line or in configuration with an SP-10 called the Integrated Slide Processor (ISP) Targeted for automation customers. Expected Release :Q CellaVision DM1200 Cell Image Analyzer : Designed for mid-size labs. Analyzes both blood and body Fluid samples CellaVision DM96 Cell Image Analyzer : Medica EasyCell assistant, Cell Image Analyzer Provides automated assistance and standardized results for blood samples for smaller laboratories. Portfolio Comparison DI-60 DM1200 EasyCell WBC Classifications RBC Morphology 6 Morphologies ID & ranked 21 categories 6 Morphologies ID & ranked 21 categories Operator selected rankings 17 categories Platelet Estimate Calculated Calculated Qualitative Peripheral Blood YES YES YES Body Fluid YES YES NO Remote Software Licenses Sample Loading Access On Board Slide Capacity (per run) YES YES YES Automated Continuous Feed Automated Continuous Feed Batch Batch Scan Time ~ 2 minutes ~ 2 minutes ~ 4 minutes Bi-Directional Interface YES YES YES 13

Case Studies Case #1 A 44-year old woman presents to her GP with the following symptoms: Bloated Feeling Heartburn Chronic Diarrhea Constipation Two months prior the patient had itchy,flat,

14 Case Studies Case #1 A 44-year old woman presents to her GP with the following symptoms: Bloated Feeling Heartburn Chronic Diarrhea Constipation Two months prior the patient had itchy,flat, red rashes with scalloped edges for which she tried topical anti-bacterial and anti-fungal creams with only limited success. Lab results were mostly normal with a slightly elevated WBC count. 14

Systemic Candida Disease Systemic Candida Disease The Candida yeast

warm and humid atmosphere are available, Candida grows

15 Systemic Candida Disease Systemic Candida Disease The Candida yeast is normally harmless and resides in the mouth and the digestive track. When your immune system is lowered or favorable conditions like warm and humid atmosphere are available, Candida grows uncontrollably and becomes an infection. Systemic Candida is most often caused by a simple infection that goes untreated or insufficiently treated. 15

He told them he had just returned from visiting family. Nothing out of the ordinary.

16 Case #2 A 35 year old man went to visit relatives for vacation. Two weeks after his return, he presented to the ER and told them he wasn t feeling well. He told them he had just returned from visiting family. Nothing out of the ordinary. He reported high fevers, shaking chills, and flu-like symptoms. Upon examination he was found to have an enlarged liver and spleen Lab Results: see below along with a slightly elevated TBili WBC RBC 3.14 HGB 9.1 HCT 27 PLT 107 %Neut 84 %LY 12 %MO 3 %EO 1 %BAS 0 Did anyone ask him where his family lived? Case #2 Image A 16

17 Case #2 Image B Plasmsodium Vivax 17

18 Plasmodium Vivax Malarial parasites work by digesting red cell proteins and making the RBC membrane less deformable, causing hemolysis, increased splenic clearance, and anemia. Red cell lysis stimulates release of cytokines and TNF-α. The systemic manifestations of malaria such as headache, fever and rigors, nausea and vomiting, diarrhea, anorexia, tiredness, aching joints and muscles, thrombocytopenia, immunosuppression, coagulopathy, and central nervous system manifestations have been largely attributed to the various cytokines released in response to these parasite and red cell membrane products P. Vivax makes up 16% of cases reported in US Not found in West Africa as no Duffy Antigen, which is required for entry in to the RBC. Characterized by: Low to Normal Platelet Count Anemia White blood cell (WBC) counts during malaria are generally characterized as being low to normal, a phenomenon that is widely thought to reflect localization of leukocytes away from the peripheral circulation and to the spleen and other organs, rather than actual depletion or stasis. In P.Vivax it is common to see more than one stage in the life cycle at the same time in the Peripheral Blood. Case # 3 A 38 year old; HIV positive man presented at the clinic with a chronic cough, bloody sputum, fever, night sweats and recent weight loss. The MD ordered chest films as well as bacterial, fungal, and AFB cultures on the sputum. CBC values were unremarkable accept for a WBC count of

Some of the common types of infection that might lead to this condition include tuberculosis, syphilis and Rocky Mountain spotted fever.

19 Case # 3 Cell Images Monocytosis Monocytosis itself is not a disease, but a symptom. Inflammatory conditions such as infection or autoimmune disturbances are primary causes of monocytosis. Some of the common types of infection that might lead to this condition include tuberculosis, syphilis and Rocky Mountain spotted fever. Autoimmune disorders such as lupus or rheumatoid arthritis might also lead to monocytosis. Some blood disorders might lead to a high number of monocytes as well. In this particular case, Tuberculosis was the diagnosis 19

Cytochemical Stains Myeloperoxidase Strongly Positive Chloroacetate Esterase (specific) Positive a-naphthyl Acetate Esterase

20 Case # 4 19 year old Male WBC 41.5 HBG 8.7 PLT 61 MCV 90.0 PT 15.5 sec aptt 27 sec Ecchymosed (bruised) skin Bleeding Gums Fever Bleeding time greater than 30 minutes. Cytochemical Stains Myeloperoxidase Strongly Positive Chloroacetate Esterase (specific) Positive a-naphthyl Acetate Esterase (nonspecific) Negative Immunophenotyping Abnormal cells mark with CD13 and CD33, but not with HLA-DR or CD34, consistent with myeloid lineage. Cytogenetics 46, X, Y, t(15;17), (q22:q11.2) Abnormal male karyotype. Acute Myeloid Leukemia (AML) 20

21 Acute Myeloid Leukemia (AML) Auer rods can be seen in the leukemic blasts. Auer rods are classically seen in myeloid blasts of M1, M2, M3, and M4 acute leukemias. These cytoplasmic inclusions are named for John Auer, an American physiologist ( ). The increased production of blasts creates a blockade of the production of normal marrow cells, leading to a deficiency of red cells causing anemia, platelets and white blood cells that are found in the peripheral blood. AML is the most common acute leukemia that affects primarily adults and accounts for over 1 percent of cancer deaths here in the United States. AML is initially treated with chemotherapy with the intent of inducing remission. Case # 5 6 year-old boy Repeated illnesses, colds, etc. Fatigue No weight gain Initial testing: CT scan, Spinal Fluid CT Scan showed an Abdominal Mass 21

Burkitt s Lymphoma (CSF) Burkitt s Lymphoma Burkitt s Lymphoma is a non-hodgkin s Lymphoma that has an especially high incidence among children 3 to 16 years of age.

22 Burkitt s Lymphoma (CSF) Burkitt s Lymphoma Burkitt s Lymphoma is a non-hodgkin s Lymphoma that has an especially high incidence among children 3 to 16 years of age. The disease is characterized by tumors of the jaw bones and abdomen and is named after Denis Burkett, who mapped its peculiar geographic distribution across Africa in the 1950s. The Epstein-Barr virus, which causes infectious mononucleosis, is present in almost 100% of persons afflicted with Burkitt s lymphoma. Burkitt s lymphoma occurs more readily in persons who have been weakened by malaria and in persons suffering from AIDS. Research suggests that Burkitt s Lymphoma caused by a genetic mutation. Similar disease characteristics to diffuse large B cell lymphoma (DLBCL) Synonym(s): Mature B cell high-grade lymphoma; Mature B cell acute lymphoblastic leukemia, L3 type (FAB classification); Despite the fast-growing nature of this tumor, Burkitt's lymphoma is also one of the most curable types of lymphoma, depending on the stage of the disease at the time it is diagnosed. Read more: 22

23 Case #6 60 Year Old male. Abdominal pain, Neck Pain Armpit and sore throat. Night sweats and fever. Unexplained weight loss (over 10%) Swelling of lymph nodes CBC results normal w/ suspect flag for variant lymphocytes on automated differential. Flow cytometry CD19+ CD5+ Mantle Cell Lymphoma 23

24 Mantle Cell Lymphoma Mantle cell lymphoma is a non-hodgkins lymphoma that occurs in the B cells found on the outer edge of the lymph node follicle. The uncontrolled growth of these B cells causes the lymph nodes to swell. Mantle cell lymphoma can also affect the bone marrow, liver and gastrointestinal tract. Though it looks like a slow growing, low-grade tumor under the microscope, it grows fast and behaves like a high-grade lymphoma. Mantle cell lymphoma accounts for approximately six percent of all non-hodgkin's lymphoma related diseases, according to The Leukemia and Lymphoma Society. The overall 5 year survival rate for MCL is generally 50% (advanced stage MCL) to 70% (for limited-stage MCL). Case #7 61 year old man Previous diagnosis of myelofibrosis Complaining of an increase in bone pain and fatigue with shortness of breath No Auer Rods seen in blasts WBC 91.4 Segs 32 RBC 2.41 Bands 17 HGB 9.0 Lymphs 13 HCT 27.6 Monos 1 MCV 115 Eos 2 PLT 412 Meta 9 Myelo 18 Pro 7 NRBC 1 Blast 1 24

25 Worsening Progression of Myelofibrosis Metamyelocytes 25

26 Myelocytes Promyelocytes 26

27 Myelofibrosis Myelofibrosis is currently classified as a myeloproliferative disease Where the replacement of the marrow with collagenous connective tissue fibers occurs. This replacement impairs the patient's ability to generate new blood cells. This is a fairly typical progression which will most likely continue with thrombocytopenia, gout, and often an acute leukemia. Only known cure is a bone marrow transplant. Other treatments are merely supportive. Case #8 53 year old woman from Connecticut, no recent travel Fatigue, malaise, loss of appetite Occasional fever WBC 6.8 Segs 58 RBC 3.54 Bands 2 HGB 10.9 Lymphs 15 HCT 31.2 Monos 9 MCV 92 Eos 2 PLT 123 Reactive Lymphs 14 Retic 3.8% Elevated ESR Liver function tests: Elevated TBili, LDH, and liver transaminases 27

28 Case #8 Image A Babesia 28

29 Babesiosis Where do most of the cases of babesiosis occur in the United States? Tickborne transmission of B. microti primarily occurs in the Northeast and upper Midwest, particularly in parts of New England, New York State, New Jersey, Wisconsin, and Minnesota. In the Northeast, babesiosis occurs in both inland and coastal areas, including off-shore islands such as Nantucket and Martha s Vineyard (Massachusetts); Block Island (Rhode Island); and Shelter Island, Fire Island, and eastern Long Island (New York State). Other possible ways of becoming infected with Babesia include: Receipt of a contaminated blood transfusion (no tests have been licensed yet for donor screening); or Transmission from an infected mother to her baby during pregnancy or delivery. The Centers for Disease Control and Prevention have issued a warning about babesiosis. According to the CDC the illness is transmitted through blood transfusions and has infected at least 122 people since This was released on Sept. 7, Case #9 A 47 year old woman who is an avid spelunker came to her doctor with complaints of: malaise (a general ill feeling) fever dry or nonproductive cough headache shortness of breath joint and muscle pains chills She also noted this sore on her forehead. The physician ordered a CSF due to her severe headache. 29

30 Overview of CSF Histoplasmosis 30

31 Histoplasmosis Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. Symptoms of this infection vary greatly, but the disease primarily affects the lungs. Histoplasmosis is common among AIDS patients because of their suppressed immune system. H. capsulatum grows in soil and material contaminated with bird or bat droppings (guano).the fungus has been found in poultry house litter, caves, areas harboring bats, and in bird roosts (particularly those of starlings). Histoplasmosis can be diagnosed by samples containing the fungus taken from sputum, blood, or infected organs. It can also be diagnosed by detection of antigens in blood or urine samples by ELISA or PCR. It can also be diagnosed by a test for antibodies against Histoplasma in the blood. Case #10 17 year old African- American girl Presents in the ER with Fever, joint pain, nausea and severe chest pain with shortness of breath CBC results upon presentation: WBC 12.9 RBC 2.64 HGB 8.7 HCT 25.4 MCV 95 RDW 28.7 PLT 238 Retic

Sickle Cell Crisis Sickle Cell Disease Sickle-cell disease (SCD), or sickle-cell anemia, is a recessive genetic blood disorder characterized by RBCs that assume an abnormal, rigid, sickle shape.

There are different types of crisis events, including vaso-occlusive, aplastic, and hemolytic. Crisis events can be caused by physical stress, changes in temperature or seasons, emotional stress, etc.

32 Sickle Cell Crisis Sickle Cell Disease Sickle-cell disease (SCD), or sickle-cell anemia, is a recessive genetic blood disorder characterized by RBCs that assume an abnormal, rigid, sickle shape. Sickling decreases the cells' flexibility and results in a risk of various complications. The sickling occurs because of a mutation in the hemoglobin gene. There are different types of crisis events, including vaso-occlusive, aplastic, and hemolytic. Crisis events can be caused by physical stress, changes in temperature or seasons, emotional stress, etc. Different people have different triggers. The length of a crisis can very considerably. Hemolytic crises characterized by acute, accelerated drops in hemoglobin level. The red blood cells break down at a faster rate. Management is supportive and often involves blood transfusions. 32

33 Case #11 16 year old female Fever, Chills, Malaise, Headache Cell Morphology 33

Mononucleosis Predominant Cells in Differential Mononucleosis Infectious Mononucleosis Sometimes called the kissing disease due to its oral transmission is an infectious, widespread viral disease

34 Mononucleosis Predominant Cells in Differential Mononucleosis Infectious Mononucleosis Sometimes called the kissing disease due to its oral transmission is an infectious, widespread viral disease caused by the Epstein Barr virus. Mono can be spread through contact with saliva, mucus from the nose and throat, and sometimes tears. Usually only self-care is needed for mono. Get plenty of rest. You may need bed rest, which could keep you away from school or work for a little while. Take acetaminophen or ibuprofen to reduce fever and relieve a sore throat and headaches. Avoid contact sports and heavy lifting. Your spleen may be enlarged, and impact or straining could cause it to burst. In severe cases, medicines called corticosteroids may be used to reduce swelling of the throat, tonsils, or spleen. 34

35 Case #12 70 year old male (Known Oncology Patient) Presents with Shortness of Breath Fever Lethargy Pleural Fluid Aspiration Cyto-Spin Prep Malignant Cells Found in Pleural Fluid 35

$Metastatic B-Cell Lymphoma Metastatic B-Cell Lymphoma Some patients may relapse (disease returns after treatment) or become refractory (disease does not respond to treatment), or the disease may$

36 Metastatic B-Cell Lymphoma Metastatic B-Cell Lymphoma Some patients may relapse (disease returns after treatment) or become refractory (disease does not respond to treatment), or the disease may spread (metastasize) to other organs. Numerous treatment options exist for patients with relapsed or refractory NHL, which are often referred to as secondary therapies. Many of the novel therapeutic agents that have been approved by the United States Food and Drug Administration, as well as those being investigated in clinical trials, focus specifically on those with relapsed or refractory disease. Potential Treatments Include: Chemotherapy Radiation Therapy Stem Cell Transplantation Novel Targeted Agents Newer Versions of Established Agents 36

37 Case #13 44 year old female (Known Oncology Patient) Post Treatment Follow-up Blood Work 37

CML with Circulating Megakaryocytes Critical Observation Platelet Blebs Chronic Myeloid Leukemia Clinical features of CML include the following: Fever, fatigue, night sweats, and weight loss.

38 CML with Circulating Megakaryocytes Critical Observation Platelet Blebs Chronic Myeloid Leukemia Clinical features of CML include the following: Fever, fatigue, night sweats, and weight loss. Increased Risk of Infection. Bleeding caused by thrombocytopenia. In patients with normal or slightly decreased white blood cell count, clinical features may be identical to MDS. In patients with elevated white blood cell count, features are more like chronic myeloproliferative disorders (CMPD), including more frequent splenomegaly and hepatomegaly. 38

39 Case #14 83 year old man Fatigue Lethargy Had removed a tick three weeks ago. RBC Characterization 39

Erlichia (Anaplasmosis) Anaplasmosis Anaplasmosis is often characterized by sudden high fever, fatigue, muscle aches, headache.

Severely ill patients can have low white blood cell count, low platelet count, anemia, elevated liver enzymes, kidney failure and

Deaths have occurred There are two kinds of ehrlichiosis, both of which are caused by tick-borne rickettsial parasites called

In HGE (human granulocytic ehrlichiosis), they infect granulocytes. HGE was renamed anaplasmosis in 2003.

40 Erlichia (Anaplasmosis) Anaplasmosis Anaplasmosis is often characterized by sudden high fever, fatigue, muscle aches, headache. The disease can be mild or life-threatening. Severely ill patients can have low white blood cell count, low platelet count, anemia, elevated liver enzymes, kidney failure and respiratory insufficiency. Older people or people with immune suppression are more likely to require hospitalization. Deaths have occurred There are two kinds of ehrlichiosis, both of which are caused by tick-borne rickettsial parasites called Ehrlichia that infect different kinds of white blood cells. In HME (human monocytic ehrlichiosis), they infect monocytes. In HGE (human granulocytic ehrlichiosis), they infect granulocytes. HGE was renamed anaplasmosis in It is likely that the lone star tick transmits HME and that the deer tick transmits HGE. Ehrlichiosis (HME) was originally thought to be only an animal disease. It was described in humans in 1987 and is now found in 30 states, predominately in the southeast, south-central, and mid-atlantic states 40

41 Case #15 50 year old woman Dyspepsia Further testing reveals that she is positive for H. Pylori Mott Cells (Russel Bodies) 41

42 Mott Cells Mott cells are plasma cells filled with Russell bodies and are found in large numbers in lymphoid organs Russell bodies occur as a result of a block in the normal pathways of immunoglobulin secretion in plasma cells. Russell bodies have been reported in many types of chronic inflammation Plasma cells are found together with lymphocytes, neutrophils and eosinophils in chronic gastritis. Russell body gastritis has been considered by some to be a different presentation of Helicobacter pylori gastritis and the mechanism may be plasma cell hyperactivation caused by chronic H. pylori infection and the immunoglobulin overproduction leading to Russell body formation. Summary Automated Cell Image Analysis in the Clinical Lab can be useful for many reasons including: Operational Capabilities Ease of viewing and manipulating images Saving time, faster TAT More consistent training and learning for technologists Long term storage of these images Attractive Ergonomics for Staff Clinical Capabilities Ease of Sharing images for Real-Time Consultation Faster and more reliable diagnoses Improved Patient Care 42

43 Questions Thank You 43

9/23/2018. Hematology Case Studies Jason Anderson, MPH, MT(ASCP) Field Product Specialist OBJECTIVES FLUORESCENT FLOW CYTOMETRY

9/23/2018. Hematology Case Studies Jason Anderson, MPH, MT(ASCP) Field Product Specialist OBJECTIVES FLUORESCENT FLOW CYTOMETRY Hematology Case Studies Jason Anderson, MPH, MT(ASCP) Field Product Specialist OBJECTIVES Discuss how scattergram and histogram pictures can provide insight into abnormal hematology samples Utilize case