CASE 1

Normal peripheral blood smear

A normal complete blood count (CBC) and normal peripheral blood smear are shown.

CASE 2

History:

A 72-year-old man has had increasing fatigue for the past 5 months. He becomes short of breath after ascending a flight of stairs. On physical examination he is afebrile with pulse 101/min, respiratory rate 17/min, and blood pressure 110/70 mm Hg. Laboratory studies include a CBC with peripheral blood smear, as shown.

Image 2.1:

Image 2.2:

• Demonstrate how to estimate the red blood cell size.

1. What is the diagnosis from these findings?

2. Which of the following tests would be most useful to determine the etiology of his condition?

A. Hemoglobin electrophoresis

B. Reticulocyte count

C. Stool for occult blood

D. Vitamin B12 assay

E. Bone marrow biopsy

3. How is this condition treated?

4. Define populations at risk for this condition.

CASE 3

History:

A 48-year-old man has become progressively more fatigued at the end of the day. This has been going on for the past 6 months. In the past month he has noted paresthesias with numbness in his hands and feet. On physical examination he has decreased vibration and position sensation in both hands and feet. Laboratory studies include a CBC with peripheral blood smear.

Image 3.1:

Image 3.2:

1. What is the diagnosis from these findings?

2. Which of the following tests would be most useful to determine the etiology:

A. Hemoglobin electrophoresis

B. Reticulocyte count

C. Stool for occult blood

D. Vitamin B12 assay

E. Bone marrow biopsy

3. How do you explain the neurologic findings?

4. How do treat this condition?

CASE 4

History:

A 30-year-old woman has the onset of fever, abdominal pain, nausea over the past day. On physical examination her vital signs include temperature 38 C, pulse 102/minute, respirations 20/minute, and blood pressure 95/50 mm Hg. She has scleral icterus. Her spleen tip is palpable, but there is no lymphadenopathy or hepatomegaly. She has Hgb 11.1 g/dL, Hct 28.8%, MCV 77 fL, platelet count 273,400/microliter, and WBC count 8900/microliter. The direct and indirect Coombs tests are negative. A month ago, a CBC showed the following findings:

Image 4.1:

Image 4.2:

• Discuss the terms reticulocytosis and polychromasia.

1. What is the diagnosis from these findings?

2. The probable association(s) with this disease is(are):

A. Autosomal dominant, European ancestry

B. X-linked, Asian ancestry

C. Autosomal recessive, Middle Eastern ancestry

D. Autosomal recessive, West African ancestry

E. Sporadic occurrence




3. 3. Which of the following is most likely to initiate an aplastic crisis in this patient?

A. Quinacrine

B. Parvovirus infection

C. Decreased oxygen tension

D. Exposure to cold

E. Transfusion

CASE 5

History:

A 29-year-old woman with a diagnosis of acute promyelocytic leukemia has developed petechiae and ecchymoses over the skin of her trunk and extremities in the past 3 days. On physical examination her vital signs include temperature 37.2 C, pulse 101/minute, respirations 19/minute, and blood pressure 85/45 mm Hg. Laboratory studies include a CBC showing Hgb 8.7 g/dL, Hct 24.5%, MCV 85 fL, platelet count 17,000/microliter, and WBC count 8700/microliter.

Image 5.1:

1. What is the diagnosis from these findings?

2. Discuss the conditions in which this can occur.

3. Which of the following tests would be most useful to diagnose this condition in this patient with acute promyelocytic leukemia:

A. Hemoglobin electrophoresis

B. Reticulocyte count

C. Coagulation tests

D. Vitamin B12 assay

E. Bone marrow biopsy

Additional History:

For comparison, a CBC from a patient with maternal HELLP syndrome is shown below. Spot the key feature in the RBC histogram.

Image 5.2:

CASE 6

History:

A 20-year-old African-American man comes to the emergency room because of the sudden onset of severe abdominal pain. On physical examination he has diffuse, severe abdominal tenderness. Bowel sounds are absent. His sclerae appear icteric. A plain film radiograph of the abdomen shows no free air, only dilated loops of bowel. Laboratory studies include a CBC that shows Hgb 4.8 g/dL, Hct 12.8%, MCV 80 fL, platelet count 205,000/microliter, and WBC count 9800/microliter with differential count showing 70 segs, 7 bands, 22 lymphs, and 3 monos, with 12 NRBC's per 100 WBC's.

Image 6.1:

Image 6.2:

• Discuss the demographics of this disease

1. What is the diagnosis from these findings?

2. Which of the following tests would be most useful to determine the etiology:

A. Hemoglobin electrophoresis

B. Reticulocyte count

C. Stool for occult blood

D. Vitamin B12 assay

E. Bone marrow biopsy




3. 3. The "crisis" in this patient was initiated by:

A. Quinacrine ingestion

B. Parvovirus infection

C. Decreased oxygen tension

D. Exposure to cold

E. Transfusion therapy

4. 4. What is your response when this patient demands a large amount of pain medications?

CASE 7

History:

This CBC demonstrates the findings following treatment for one of the conditions given above.

Image 7.1:

1. Can you determine what that treatment was?

2. What issues arise when the patient refuses this therapy? What if the patient is a child and parents refuse therapy?

CASE 8

The Task:

Shown below are four patient histories, with links to four pathologic images and four maps of geographic locations. Match each history to the appropriate image and most probable location for a patient with the disease process shown.

• History A: A 26-year-old woman has had an irregular fever with chills, diaphoresis, myalgias, and fatigue for the past 2 weeks. On physical examination her vital signs include T 37.8 C, P 73/minute, RR 16/minute, and BP 110/70 mm Hg. She has mild hepatosplenomegaly but no lymphadenopathy. Laboratory studies show Hgb 12.3 g/dL, Hct 37.1%, MCV 96 fL, platelet count 217,800/microliter, and WBC count 7890/microliter. Her reticulocyte count is 3.2%. Her serum haptoglobin is 0.8 mg/dL.

• History B: A 32-year-old man has been bothered by a fever for the past 3 weeks. On physical examination his vital signs include T 37.5 C, P 76/minute, RR 15/minute, and BP 125/80 mm Hg. He has an easily palpable spleen tip and mildly increased liver span. He has mild generalized lymphadenopathy. Laboratory studies show Hgb 11.7 g/dL, Hct 34.9%, MCV 83 fL, platelet count 139,200/microliter, and WBC count 2275/microliter.

• History C: A 9-year-old girl has complained of a headache for the past 2 days. She then has the sudden onset of convulsions. On physical examination her vital signs include T 38.8 C, P 92/minute, RR 19/minute, and BP 85/50 mm Hg. Her spleen is palpable. She remains comatose. Laboratory studies show Hgb 5.1 g/dL, Hct 15%, MCV 100 fL, platelet count 82,000/microliter, and WBC count 9825/microliter. Her serum creatinine is 2.8 mg/dL, glucose 39 mg/dL, and total bilirubin 2.9 mg/dL.

• History D: A 12-year-old boy has not been eating well for the past week and has been listless. On physical examination vital signs include T 37.8 C, P 82/minute, RR 18/minute, and BP 90/55 mm Hg. He has periorbital edema and lower extremity edema. There is a morbilliform rash over his trunk. He has generalized lymphadenopathy. On auscultation of his chest lung fields are clear. He has an irregular heart rate.

Images

Maps