case

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case

• A 16-year-old boy is brought to the emergency
  department by his parents because he has been
  complaining of severe abdominal pain for the past
  day. On physical examination, he had a rigid,
  board-like abdomen and rebound tenderness in the
  right lower quadrant. His vital signs include
  temperature 38.3 C (101 F), pulse 84/minute,
  respirations 16/minute, and blood pressure 110/65
  mm Hg. Laboratory studies include a CBC showing
  Hgb 14.8 g/dl, Hct 44.4, MCV 90 fL, platelet
  count 240,000/microliter, and WBC count
  20,000/microliter. A urinalysis is normal. His
  peripheral blood smear is shown

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• Leukocytosis vs Leukopenia
• Leukamoid Reaction vs Leukemia

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case

• A 15-year-old previously healthy girl is sent
  home from summer camp because she has exhibited
  weakness, lassitude, and complaint of a sore
  throat for the past 3 days. On physical
  examination she has pharyngeal erythema and
  enlarged tonsils without overlying exudate. She
  has several enlarged and slightly tender lymph
  nodes in her neck. She has a palpable spleen and
  a tender palpable liver edge. Laboratory studies
  include a CBC showing Hgb 14.9 g/dl, Hct 44.9,
  MCV 92 fL, platelet count 282,100/microliter, and
  WBC count 12,500/microliter. Her peripheral blood
  smear is shown

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Questions

• ? Cells
• Diagnosis?
• DD
• Confirmation

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case

• A 30-year-old man has noted progressive weakness
  over the past month. On physical examination he
  has a few small non-tender lymph nodes palpable
  in both axillae, and the tip of his spleen is
  palpable. There is also sternal tenderness
  present on palpation, but no mass lesion or
  overlying skin changes. Laboratory studies
  include a CBC that shows Hgb 10.2 g/dl, Hct
  30.5, MCV 88 fL, platelet count
  36,000/microliter, and WBC count
  67,000/microliter. His peripheral blood smear is
  shown

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questions

• Prominent cells?
• Diagnosis
• Dianostic finding?
• Morphology
• p/s
• Marrow
• stain

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case

• A 65-year-old man has been in good health except
  for hypertension treated with a thiazide. On
  physical examination he has several slightly
  enlarged non-tender lymph nodes in his neck and
  both axillary regions. His spleen is palpable.
  Laboratory studies with CBC show Hgb 11.8 g/dl,
  Hct 35.6, MCV 85 fL, platelet count
  130,000/microliter, and WBC count
  44,500/microliter. His peripheral blood smear
  findings are shown

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Questions

• Diagnosis
• Specific cell?
• Prominent cells
• Treatment

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case

• A 52-year-old man has had gradually increasing
  fatigue for the past 4 months together with
  worsening discomfort in the left upper quadrant.
  Physical examination reveals an easily palpable
  spleen and liver edge. A few slightly enlarged
  non-tender lymph nodes are palpable in the
  cervical region. Laboratory studies show Hgb 12.2
  g/dl, Hct 36.7, MCV 93 fL, platelet count
  754,000/microliter, and WBC count
  246,000/microliter. His peripheral blood smear
  findings are shown

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• P/S findings
• Diagnosis
• LAP or NAP
• Cytogenetics
• Treatnent

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case

• A 5-year-old girl has become increasingly
  listless for the past 2 months. Her mother notes
  that, whenever she falls or bumps into anything,
  a big bruise forms. For the past 2 days she has
  had a high fever. On physical examination vital
  signs include temperature 39.3 C, pulse
  90/minute, respirations 21/minute, and blood
  pressure 95/60 mm Hg. Laboratory studies show Hgb
  9.8 g/dL, Hct 29.6, MCV 95 fL, platelet count
  74,000/microliter, and WBC count 2,300 with
  differential count 23 segs, 15 bands, 12 monos,
  44 lymphs, 5 eos, and 1 baso. A bone marrow
  biopsy is performed and on microscopic
  examination shows replacement by primitive cells
  that have large nuclei with delicate chromatin
  and indistinct nucleoli. There is scanty
  cytoplasm with no granules and no Auer rods.
  These cells mark for CD10 (CALLA) antigen. Her
  peripheral blood smear is shown

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Questions

• Prominent findings
• Diagnosis
• Special tests

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case

• A 3 year old boy has had multiple episodes of
  pneumonia with Staphylococcus aureus and urinary
  tract infections with beta-hemolytic
  Streptococcus in the past 6 months. He had been
  born at term to a 22-year-old woman. He was noted
  at birth to have no congenital anomalies. He did
  well during infancy. His only sibling, a
  5-year-old sister, has had no major medical
  problems. On physical examination he has blond
  hair and blue eyes (everyone else in the family
  has a darker complexion). He has contusions of
  multiple ages on his extremities. A CBC shows Hgb
  13.8 g/dL, Hct 41.5, MCV 85 fL, Platelet count
  176,000/microliter, and WBC count
  4,080/microliter with differential count of 45
  segs, 2 bands, 40 lymphs, and 13 monos. Serum
  quantitative immunoglobulins show IgA 71 mg/dL
  (16 - 83 mg/dL), IgG 901 mg/dL (282 - 1026
  mg/dL), and IgM 109 mg/dL (39 - 142 mg/dL). His
  peripheral blood smear is shown

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Questions

• Prominent finding
• Diagnosis
• Mechanism

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Lymph node
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case

• A 64-year-old man has noted lumps in his neck and
  axillae for approximately one year. These lumps
  had disappeared 5 months ago and then had
  recurred. He is otherwise asymptomatic. On
  physical examination, he has several non-tender,
  movable, rubbery 1 to 3 cm lymph nodes palpable
  in both sides of his neck and in his axillae. On
  abdominal examination, the spleen tip is
  palpable. A CBC shows WBC count 7700/microliter,
  Hgb 11.9 g/dL, Hct 36, MCV 85 fL, and platelet
  count 207,000/microliter. An axillary lymph node
  biopsy is performed

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Questions

• Prominent findings
• Diagnosis
• Important features

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case

• A 61-year-old woman has had bouts of of abdominal
  pain along with a 3 kg weight loss over the past
  2 months. Physical examination reveals no
  palpable peripheral lymphadenopathy. She has no
  hepatosplenomegaly. A stool sample is negative
  for occult blood. A CBC reveals Hgb 13.1 g/dL,
  Hct 40.0, MCV 96 fL, platelet count
  287,000/microliter, and WBC count
  8850/microliter. An abdominal CT scan shows an 8
  x 10 cm solid mesenteric mass. A biopsy of the
  mass is performed.

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Biopsy
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Questions
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case

• A 27-year-old woman presents to her physician
  with a month-long history of dull chest pain. She
  has no dyspnea and reports no hemoptysis. On
  physical examination, her lungs are clear to
  auscultation. She has no lymphadenopathy or
  hepatosplenomegaly. She does have plethora of the
  head and neck region. A CBC shows Hgb 13.1 g/dL,
  Hct 39.5, MCV 91 fL, platelet count
  215,000/microliter, and a WBC count of
  6350/microliter. Resection of a lesion is
  performed.

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case

• A 66-year-old man had been complaining of back
  pain for the past 5 months, for which he had
  taken non-steroidal anti-inflammatory
  medications, but the dull pain persisted. On
  physical examination he has no abnormal findings.
  Radiographs of the spine and pelvis show lytic
  bone lesions at T11, T12, L2, and in the right
  posterior iliac crest. A radiograph of the skull
  shows multiple lytic lesions. His CBC shows Hgb
  10.8 g/dL, Hct 32.2, MCV 89 fL, platelet count
  135,000/microliter, and WBC count
  4890/microliter. A serum chemistry panel shows
  sodium 140 mmol/L, potassium 4.0 mmol/L, chloride
  98 mmol/L, CO2 24 mmol/L, urea nitrogen 32 mg/dL,
  creatinine 2.9 mg/dL, glucose 79 mg/dL, calcium
  11.6 mg/dL, phosphorus 2.2 mg/dL, AST 30 U/L, ALT
  23 U/L, alkaline phosphatase 249 U/L, total
  bilirubin 0.9 mg/dL, albumin 3.5 g/dL, and total
  protein 9.6 g/dL. A urinalysis shows sp gr.
  1.020, pH 6.5, and no glucose, protein, or blood.
  A posterior iliac crest bone marrow biopsy is
  performed.

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case

• A 60-year-old woman has had worsening nausea and
  vague epigastric abdominal pain for the past 6
  months. She has tried taking calcium containing
  antacids without relief. She does not report
  hematemesis. On physical examination there are no
  abnormal findings. Laboratory studies show Hgb
  13.5 g/dL, Hct 43.7, MCV 87 fL, platelet count
  303,600/microliter, and WBC count
  8050/microliter. An upper GI endoscopy is
  performed and there is diffuse erythema of the
  gastric mucosa along with a 3 x 4 cm area of
  nodular, raised antral mucosa that lacks rugal
  folds and has focal erosions. Biopsies are taken.
  A CT scan of the chest and abdomen shows focal
  antral thickening, but no lymphadenopathy,
  hepatomegaly, or splenomegaly. A bone marrow
  biopsy is unremarkable. She has a positive urea
  breath test.

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