Drop of Blood Unravels Mysteries. Prof. Salma Afrose Department of Hematology Dhaka Medical College

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1 Drop of Blood Unravels Mysteries Prof. Salma Afrose Department of Hematology Dhaka Medical College

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3 Peripheral Blood Film (PBF) PBF is a laboratory workup that involves cytology of Peripheral blood cell smear on a slide

4 Clinical history Physical examination Lab investigation Diagnosis

5 Importance of PBF Basic & highly informative hematological tool for Screening Diagnosis Monitoring disease progression & Therapeutic response So for successful clinical practice understanding interpretation of PBF is essential

6 Indication Clinical request from attending clinician (based on clinical suspicion) Sometimes from laboratory due to abnormal finding on an automated counter Unexplained cytopenia Unexplained leukocytosis, lymphocytosis, monocytosis Unexplained hemolysis or jaundice Sepsis Liver failure Hematological malignancies Severe bacterial sepsis Parasitic infection Anemia evaluation

7 Clinical indications for examination of PBF Features suggestive of anemia, unexplained jaundice, or both Features suggestive of sickle cell disease dactylitis or sudden splenic enlargement and pallor in a young child or, in an older child or adult, limb, abdominal, or chest pain Features suggestive of thrombocytopenia (e.g. petechiae or abnormal bruising) or neutropenia (e.g. unexpected or sever infection) Features suggestive of a lymphoma or other lymphoproliferative disorder lymphadenopathy, splenomegaly, enlargement of the thymus (a mediastinal mass on radiology) or other lymphoid organs, skin lesions suggestive of infiltration, bone pain, and systemic symptoms such as fever, sweating, itching and weight loss Features suggestive of a myeloproliferative disease splenomegaly, plethora, itching or weight loss

8 Clinical indications for examination of PBF (contd.) Suspicion of disseminated intravascular coagulation Acute or recent-onset renal failure or unexplained renal enlargement, particularly in a child On retinal examination, hemorrhages, exudates, signs of hyperviscosity, or optic atrophy Suspicion of a bacterial or parasitic disease that can be diagnosed from a blood smear Features suggestive of disseminated nonhematopoietic cancer weight loss, malaise, bone pain General ill health, often with malaise or fever, suggesting infectious mononucleosis or other viral infection or inflammatory or malignant disease

9 Interpretation Key Features in the blood film Red cells Size Microcytes, normal sized cells, macrocytes (a lymphocyte or segmented neutrophil can be employed for reference) anisocytosis Shape Variation from the normal round profile, for example oval, pencil, tear-drop, sickle, fragmented, crenated, burr cells and acanthocytes; poikilocytosis. Abnormality of overall configuration, for example spherocytes, target cells, stomatocytes Pattern of staining Normal intensity of hemoglobin staining, or subnormal hypochromatic cells with characteristically increased central pallor. Increased purple hue in polychromatic cells Inclusions Basophillic stippling, Howell_Jolly bodies, malarial parasites, Pappenheimer bodies, areas of deficient staining referred to as blisters. Association Clumping of red cells to form aggregates or rouleaux Abnormal cells Presence of erythroblasts

10 Interpretation (contd.) Key Features in the blood film White Cells Relative number Decreased, normal or increased Morphology Lymphocytes, monocytes, and segmented granulocytes present in normal or abnormal ratios. Presence of cells normally absent, for example immature myeloid or lymphoid cells, atypical lymphocytes, hypersegmented neutrophils, or increased proportions of band neutrophils Platelets Relative number Decreased, normal or increased Morphology Normal or enlarged forms

11 Red blood cells Automated cell counter & histogram gives information about anemia But morphologic abnormalities can only be determined by blood film Variation in cell shape Red cell inclusion

12 Disorder associated with common red cell poikilocyte Name Characteristics Also seen in Spherocytes HS, IHA Wilson disease, HA, Hb CC disease Elliptocyte HE IDA, MDS, Thallassemia, Megaloblastic anemia Tear drop cell HPP, HE Severe iron deficiency, Thallassemia, MDS, myelofibrosis Schistocyte Echinocyte MAHA, fragmentation hemolytic anemia Renal failure, malnutrition Acanthocyte Anemia in liver disease, a betalipoproteinemia Splenectomy Target cell Cholelithiasis, Hemoglobin C, liver disease Iron deficiency, Thallassemia Stomatocyte Hereditary stomatocytosis Alcoholism

13 Hemolytic Anemia HE South East Asian Ovalocytosis Spherocytosis (D/D) Microspherocyte (burn & MAHA) MAHA TTP & HUS DIC Acute hemolysis by oxidant drug 6GPD deficiency Wilson disease -Bite cell CHAD

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16 Macrocytic anemia Essential for differential diagnosis (PBF) megaloblastic anemia Ovalomacrocytosis with hypersegmentation of neutrophil Liver disease Round macrocyte, target cell, no hyper segmented neutrophil MDS Macrocytosis, dysplastic neutrophil, giant or hypo granular platelet CDA Macrocytosis with Poikilocytosis Hemolysis, Recent blood loss Macrocytosis with Polychromasia

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18 Microcytic Anemia Red cell indices & biochemical tests help in diagnosis of majority cases but film is essential to identify Pappenheimer body & Basophilic stipling in sideroblastic anemia & lead poisoning Hemoglobinopathy & Thalassemia Needed for diagnosis & D/D Sickle cell disease Rapid diagnosis Thalassemia diagnosis & status of spleen

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20 NRBC Signifies bone marrow damage or stress in some cases serious underlying disease Hemolytic anemia Megaloblastic anemia Myloproliferative disorder Multiple myloma After splenectomy Storage disease Thalassemia major MDS Sarcoidosis Sepsis

21 Effective erythropoiesis - Reticulocytosis, polychromasia, immature granulocyte Ineffective erythropoiesis NRBC without reticulocytosis

22 Red cell agglutination presence of antibody Rouleaux formation Multiple myloma Leishmaniasis Severe infection

23 White Blood Cell Morphology, distribution, granularity, nuclear configuration Leukocytosis Bacterial infection Inflammation Malignancy Tissue injury Steroid Myloproliferative disorder

24 Hyposegmented in sepsis, MDS Hyperlobated in B12 Folic Acid, MDS, drugs Toxic granulation in infection

25 Direct diagnosis from PBF APL AML Hairy cell leukemia ALL Burkitt lymphoma SLVL

26 Platelet Platelet distribution & morphology seen Thrombocytopenia PBF essential for 2 purposes Confirm thrombocytopenia small clot, clumping & platelet satellitism Look for underlying cause Morphology small platelet in Aplastic anemia Giant platelet Immun thrombocytopenia, hypersplenism Giant platelet with red cell fragment and helmet cell MAHA Thrombocytosis Microcytic hypochromic reactive Platelet anisocytosis with baseophilia myloproliferative

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28 Parasites Malaria Leishmania Filaria

29 Serendipity Fortuitous investigation that may be of diagnostic importance Red cell fragmentation Hyposplenism Cryglobenemia (hepatitis C infection) Red cell agglutination (LPD, IM) Dysplastic feature typical of HIV Malaria, leishmaniasis, filariasis Fungal infection Candidiasis Histoplasmosis Bacteria Pneumococcal infection

30 Case 1 A 10 year old boy treated as ITP for last 7 yrs a case of BSS Being large platelet Count is low in automated analyser

31 Case 2 A 45 yr old lady have been suffering from fever for last 1 yr. Her CBC shows Neutrophil leukocytosis with Monocytosis Having multiple antibiotic culture of blood, C/S even TB drugs Blood film shows CMML as Analyser can not identify some monocyte & dysplasia

32 Case 3 A middle aged man suffering from leg oedema normocytic anemia but no cause is found PBF when properly seen shows thick target cell with normocytic anemia CLD with Hepatitis C positivity

33 Case 4 A patient presented with thrombocytopenia & diagnosed as ITP. He is not responding to drugs. Going before second line drug his PBF is checked & found to have Malaria Treatment of Malaria cure him of thrombocytopenia

34 Despite major advances in hematology automation, genetic & molecular techniques in diagnosis of various diseases, PBF remains a frontline diagnostic tool for unraveling mysteries behind cryptic symptoms & signs

35 Thank you