All in a days work
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ALL in a Days Work…. A Hematology Case Study about Leukemia by Sarah Wycoff. Questions to Consider:. How do you accurately determine a leukemic blast cell from a lymphocyte? What cytochemical stains can be used to diagnose Acute Lymphoblastic Leukemia?. Patient History.

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All in a days work

ALL in a Days Work…

A Hematology Case Study

about Leukemia

by

Sarah Wycoff


Questions to consider

Questions to Consider:

  • How do you accurately determine a leukemic blast cell from a lymphocyte?

  • What cytochemical stains can be used to diagnose Acute Lymphoblastic Leukemia?


Patient history

Patient History

  • 50-year-old female

  • No prior medical problems

  • Admitted to ER with chest pain, fatigue and shortness of breath


Cbc and differential results

WBC: 20.5 bil/L (4.3-10.9)

Neutaphils: 1.84 (7.0-7.2)

Lymphocytes: 4.10 (1.1-4.5)

Monocytes: 0.21 (0.0-0.8)

Myelocytes: 0.21 (0.0)

Blast: 14.14 (0.0)

Reticylocytes: 17 bil/L (25-85)

RBC: 3.16 tril/L (3.87-5.05)

HgB: 10.4 (12.1-15.0)

MCV: 91.8 fl (80-100)

MCHC: 35.9% (33-35)

RDW: 18.1% (11.5-15.0)

Platelets: 31 Bil/L (155-442)

CBC and Differential Results


Peripheral blood smear

Peripheral Blood Smear

  • Normal lymphocyte in the middle

  • 4 blast cells in the corners


Bone marrow aspirate

Bone Marrow Aspirate

  • Cellularity is increased at 95-100%

  • Normal hematopoietic marrow is replaced by an immature lymphoid infiltrate


Normal bone marrow

Normal Bone Marrow


Cytochemial stains sbb sudan black b

Cytochemial Stains- SBB(Sudan Black B)

  • Positive control cell is the mature neutrophil (granulocytic cell line)

  • Stain determines if blasts are granulocytic

  • Patient’s blasts are negative


Cytochemial stains mpo myeloperoxidase

Cytochemial Stains- MPO(Myeloperoxidase)

  • Positive control cell is the mature neutrophil

    (granulocytic cell line)

  • Stain determines if blasts are granulocytic

  • Patient’s blasts are negative


Cytochemical stains pas periodic acid shiff

Cytochemical Stains- PAS(Periodic-Acid Shiff)

  • Positive control cells are the lymphocytic cell line and neutrophils

  • Stain will be positive in lymphocytic and erythrocytic blasts

  • Patient’s blast are slightly positive


Diagnosis acute lymphoblastic leukemia all

Diagnosis: Acute Lymphoblastic Leukemia (ALL)

  • Regarded as a childhood disease (80% of cases occur between the ages of 2 to 10)

  • ALL subtypes

    T-Cell - 20-25%

    Precursor B-cell (L1 and L2) – 70-75%

    Mature B-cell (Burkitt – L3) – 5%


Clinical manifestations of all

Clinical Manifestations of ALL

  • Malaise, fatigue and pallor –related to anemia (too few RBC’s)

  • Bruising, petechiae and epitaxis – related to thrombocytopenia (too few PLT’s)

  • Weight loss, bone pain and sternal tenderness (due to proliferation of leukemic cells in bone marrow)


Philadelphia chromosome

Philadelphia Chromosome

  • Commonly associated with CML (95% are Ph +)

  • 15% to 30% of adults with ALL are Philadelphia chromosome positive, making it the most common ALL associated chromosomal abnormality


Treatment

Treatment

  • Chemotherapy with Cyclophosphamide, Mesnex, Viacritine, Doxorubican and Decadron

  • Transferred to University of Michigan Medical Center to receive a bone marrow transplant


Summary

Summary

  • 50 year-old female admitted to ER

  • Laboratory findings suggestive of adult ALL

  • Diagnosis confirmed though cytochemisty and flow cytometry

  • Transferred to University of Michigan to receive bone marrow transplant


Answers to questions to consider

Answers to Questions to Consider

  • Blasts have a higher nucleus to

    cytoplasm (N:C) ratio and finer chromatin pattern than normal lymphocytes

  • Cytochemical stains used to diagnosis Acute Lymphocytic Leukemia:

    • MPO negative

    • SBB negative

    • PAS positive


Credits

Credits

This case study was prepared by

Sarah Wycoff, MT(ASCP)

while she was a Medical Technology student in the

2004 Medical Technology Class at

William Beaumont Hospital in Royal Oak, MI.


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