CASE STUDIES PERIPHERAL BLOOD AND BODY FLUIDS

Transcription

1 CASE STUDIES PERIPHERAL BLOOD AND BODY FLUIDS WHERE TO START anemias hemoglobinopathies new and old parameters uncommon things fluids.benign and malignant.yuk! really annoying stuff and maybe some entertainment But not necessarily in that order 1

2 RBCs and PLATELETS WHAT S IMPORTANT HGB MCV HCT RETICS MCHC RDW IRF IPF RET-He huh? 2

3 Old and new parameters What they are and why you should use them RDW.red cell distrubution width IRF.immature retic fraction RET-He reticulocyte hemoglobin content IPF.immature platelet fraction Notes on the RDWs RDW-CV RDW-SD They are not the same all the time 3

4 RDW-SD and RDW-CV ANEMIA CLASSIFICATION IRON DEFICIENCY THALASSEMIA MINOR RDW CV ELEVATED (NORMAL 11 13) RDW CV NORMAL RDW SD ELEVATED (NORMAL 39 49) RDW SD DECREASED THE RDW IT S SUPPOSED TO HELP IRON DEFICIENCY ANEMIA OF CHRONIC DISEASE THALASSEMIA MINOR RDW SD 55.7 RDW SD 57.9 RDW SD 33.8 RDW CV 22.1 RDW CV 20.4 RDW CV

5 They are not the same THE RDW-CV IS LESS RELIABLE WHEN THE MCV IS ABNORMAL OOPS! 5

6 IRF Immature Retic Fraction (SORT OF THE LEFT SHIFT OF THE RETICS) LFR = LOW FLUORESCENT RATIO MFR = MEDIUM FLUORESCENT RATIO HFR = HIGH FLUORESCENT RATIO MFR + HFR = IRF IRF WHAT IT TELLS YOU RED BLOOD CELLS ARE BEING PUSHED OUT OF THE MARROW EARLY OR THEY RE NOT 6

7 RET-He Sort of the MCH of the Retics Do the retics have enough iron available for Hemoglobinzation Sensitive monitor of iron availability IPF IMMATURE PLATELET FRACTION SORT OF THE RETICS OF THE PLATELETS In fact very young platelets are called reticulated platelets. 7

8 IPF Immature platelet fraction Measures platelets newly released from the bone marrow Indicates thrombopoiesis (or not) Forward Scatter mature platelets Fluorescence IPF Differential Diagnosis of Thrombocytopenia Decreased Production LOW IPF Aplastic anemia Leukemia Marrow suppression Drugs Increased Destruction HIGH IPF Immune Thrombocytopenia (ITP), Thrombotic Thrombocytopenic Purpura TTP Disseminated intravascular coagulation (DIC) Drugs 8

9 FINALLY. CASE STUDIES M/90 ANEMIA 9

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11 F/74 ANEMIA and THROMBOCYTOPENIA and 11

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13 WHY WAS THE OPTICAL PLATELET COUNT NOT CHOSEN? MORE TYPICAL ITP (idiopathic thrombocytopenic purpura) 13

14 F/48 ANEMIA and THROMBOCYTOPENIA 14

15 DAY 3 TTP (THROMBOTIC THROMBOCYTOPENIC PURPURA) M/59 oncology DECREASED PLATELET PRODUCTION 15

16 F/37 SURPRISE QUIZ! 16

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18 F/11 SICKLE CELL CRISIS WHAT S IMPORTANT IN SICKLE CRISIS? DO THEY HAVE RETICS OR NOT 18

19 F / 11 SICKLE CELL DISEASE RETIC 355,100 /ul (9.9%) IMMATURE RETIC FRACTION 34% M/ 23 SICKLE CELL CRISIS RETIC 22,800 /ul (12.0%) IMMATURE RETIC FRACTION 9.6% 19

20 DAY 1 DAY 2 RETIC 22,800 /ul RETIC 9,200 /ul IRF 9.6% IRF 30.4% AND JUST FOR FUN. F/17 20

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22 BERNARD SOULIER SYNDROME QUESTIONS?? AND IT S ON TO BODY FLUIDS 22

23 BODY FLUID STUFF AND CASE STUDIES BODY FLUID STUFF CELL COUNTING BENIGN AND MALIGNANT CELLS 23

24 CELL COUNTING BEFORE YOU START ANY TYPE OF CELL COUNTING.THERE ARE SOME RULES FIRST. SYNOVIAL FLUIDS SHOULD BE TREATED WITH HYALURONIDASE 24

25 IT S A SECOND. TOTAL NUCLEATED CELL COUNT (MACROPHAGES, MESOTHELIAL CELLS etc) NOT JUST A WBC CELL COUNTING AUTOMATED 25

26 WHY YOU WANT TO DO THIS - better precision - more efficient - safer AUTOMATED CELL COUNTS WHAT S IMPORTANT? - BACKGROUNDS - PICTURES 26

27 PICTURES SYSMEX XE2100 SYSMEX XE

28 KNOW WHEN IT S GOOD.. AND WHEN IT S NOT 28

29 SOMETHING TO REMEMBER.. THE TYPE OF CELL PRESENT IS MORE IMPORTANT THAN THE CELL COUNT. The importance of the count is is it normal, elevated, or drastically elevated 29

30 Hmmmmm.. should I dilute this? CELLS BEFORE YOU START.THERE ARE SOME MORE RULES 30

31 FIRST YOU NEED ONE OF THESE or something like it SECOND.. EVEN IF IT S CLOTTED YOU CAN DO SOMETHING WITH IT! 31

32 THE PROBLEM CELLS MESOTHELIAL CELLS MALIGNANT CELLS MESOTHELIAL CELLS 32

33 Where they come from and why they can be a problem The pleural and peritoneal membrane MESOTHELIAL individual uniform flat clusters n/c ratio low MALIGNANT cannibalism bizarre ball-like clusters n/c ratio high 33

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37 MESOTHELIAL smooth chromatin smooth nuclear membrane round/oval nuclei if multinucleateduniform minimal vacuolization MALIGNANT uneven chromatin irregular nuclear membrane nuclear clefting/molding multinucleated - nonuniform dramatic vacuolization 37

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42 CELLS THAT LOOK LIKE MESOTHELIAL CELLS.BUT THEY RE NOT! 42

43 SYNOVIAL LINING CELLS CSF NEURAL LINING CELLS EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX 43

44 BRONCHIAL LINING CELLS BRONCHIAL LINING CELLS..CARBON INCLUSIONS 44

45 MESOTHELIAL CELLS ARE FOUND ONLY IN SEROUS FLUIDS (PLEURAL, PERITONEAL, PEROCARDIAL) COOL CASE STUDIES AND TWO.. NOT SO COOL 45

46 24 YEAR OLD FEMALE SEEN IN ER FOR HEADACHE AND NAUSEA PREVIOUS HISTORY OF MENINGITIS CSF RBC 17 / mcl Nucleated cells 754 /mcl 46

47 The patient has viral meningitis more specifically a recurrence of herpes meningitis. She is positive for HSV- Type 2. Recurrent meningitis is known as Mollaret s Meningitis. Herpes meningitis occurs in 10% of cases of primary genital HSV-2. Women are at higher risk for herpes meningitis than men. Surprisingly, herpes meningitis resolves without complications in 7 10 days but can recur in some patients. 47

48 67 YEAR OLD FEMALE MEDICAL HISTORY UNREMARKABLE SEEN IN ER WITH COMPLAINTS OF HEADACHE AND DIZZINESS CSF RBC NONE SEEN Nucleated cells 135 / mcl 48

49 Very big cells or clusters of cells will appear here because they have a lot of fluorescence. 49

50 A clue is their size Another clue is the irregular nuclear chromatin and large vacuoles. These are malignant cells from metastasized breast cancer. The breast cancer was not previously diagnosed. 60 YEAR OLD MALE NO HISTORY AVAILABLE CSF RBC 37 /mcl Nucleated cells 85 / mcl (manual count) 50

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52 Cryptococcus meningitis Cryptococcus neoformans is commonly found in soil and bird droppings. It can also be found on fruits and vegetables. Most people are exposed to cryptococcus but a normal immune system prevents disease 50% of AIDS patients with a low T4 count (< 50) develop cryptococcus meningitis 67 YEAR OLD MALE 5.5 YRS POST HEART TRANSPLANT PLEURAL FLUID NUCLEATED CELLS 5,998 /mcl 52

53 Monomorphic post transplant lymphoproliferative disorder Burkitt s lymphoma 53

54 IF YOU RE WONDERING SYNOVIAL FLUID The diff channel on the XE showed interference did the WBC/BASO channel. A manual count would need to be performed but.. 54

55 URIC ACID CRYSTALS POLARIZED LIGHT RED COMPENSATOR FILTER 55

56 HOW ARE YOU GOING TO FIND THE CELLS? AND DOES IT MATTER? NOT SO COOL CASE STUDIES seriously, it can happen to anybody 56

57 47 YEAR OLD FEMALE ER PATIENT ALTERED VISION?? CSF NUCLEATED CELLS 4 / mcl RBC 3 / mcl (manual count performed because the CSF was clear and colorless) 57

58 SOMETHING TO REMEMBER. CYTOCENTRIFUGE CONCENTRATION ~ 20 FOLD IF YOU DO IT RIGHT! And CAP says you should compare the cytocentrifuge slide to the cell count 58

59 CSF automated analysis Manual recount 30 cells WHAT WENT WRONG? 59

60 NEW RULE ALL FLUIDS CLEAR, COLORLESS, WHATEVER ARE ANALYZED ON THE XE SYNOVIAL FLUID failure in the opposite direction 60

61 REPORTED SYNOVIAL FLUID EXAM FLUID APPEARANCE CLEAR COLORLESS FLUID VOLUME 3 ml NUCLEATED CELL COUNT 147 /mcl TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL JOINT FLUID CRYSTALS NONE SEEN WAIT. WHAT????? 61

62 REPORTED SYNOVIAL FLUID EXAM FLUID APPEARANCE CLEAR COLORLESS FLUID VOLUME 3 ml NUCLEATED CELL COUNT 147 /mcl TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL JOINT FLUID CRYSTALS NONE SEEN WHAT????? THANK YOU QUESTIONS?? 62