White Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions

C. William Reiquam, M. D., Elmer W. Koneman, M. D.

This collection of informative case studies covers current topics in white cell disorders. Topics include leukemoid reactions, leukocytosis, intracellular granules, intra-cytoplasmic inclusion bodies, megakaryocytes, and more. Excellent for continuing education for clinical laboratory science professionals.

Continuing Education (CE) Credits

P.A.C.E. Contact Hours: 3 hour(s)
Florida CE: General (Hematology): 3 hour(s)

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White Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions Objectives

At the conclusion of this course, the student will be able to link peripheral BLOOD white cell ABNORMALITIES with specific CLINICAL entities with 70% or more proficiency.
1. Recognize several peripheral white cell ABNORMALITIES and list the criteria necessary to request a MORPHOLOGICAL/CLINICAL review.
2. Recognize and list the criteria by which a LEUKEMOID reaction is differentiated from LEUKOCYTOSIS with a left shift.
3. Describe various INTRACELLULAR WHITE BLOOD CELL INCLUSIONS and link them with the METABOLIC, genetic, and REACTIVE conditions with which they are assocated.
4. Estimate PLATELET counts from scan of the PERIPHERAL BLOOD SMEAR and explain why machine PLATELET counts may be fallacious.
5. Present the criteria for determining CELLULARITY and how to calculate the MYELOID: ERYTHROID (M:E) RATIO aftrer the study of several examples of stained BONE MARROW smears.
6. Score 70% or greater in answering a series of post-course self-ASSESSMENT questions.
Acknowledgements: Appreciation is expressed to Ms. Bette Jamison, MT (ASCP), Ms. Annie Elrod, MT (ASCP), John RYDER, M.D. Peter Shen, M.D., and other members of he University of Colorado HEALTH Scien

White Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions Outline

WHITE BLOOD CELL Disorders and PLATELETS:

Peripheral Smear Review Introduction

PERIPHERAL BLOOD SMEAR prepaRATIOn
Criteria for EVALUATION of WHITE BLOOD CELLS and PLATELETS
Criteria for requesting a HEMATOLOGIST's review of the smear.
LYMPHOCYTES displayed in the photograph most likely would be called atypical or REACTIVE. A quantitative estimate of the number of such cells may be useful using terminology such as mild (or 1+), moderate (2+) or many (3+). What percentage of the total white BLOOD count would a report of moderate or 2+ atypical LYMPHOCYTES indicate?
Atypical Cells: Quantitative Estimate
Assume that several other LYMPHOCYTES similar to the one in the center of the photograph are found on review of the peripheral smear. A work up for LEUKEMIA should be recommended.
PLATELET Estimate
An electronic PLATELET count of 40,000/cumm was reported. Review of the PERIPHERAL BLOOD SMEAR(see photograph)reveals single PLATELETS in open fields and PLATELET clumps. The PLATELET count is likely incorrect.
Additional comments on this exercise

1. LEUKEMOID Reaction vs TOXIC Changes

The neutrophils illustrated in this photograph are representative of those seen in the smear. The total WBC was 28,500 cells/cumm. The appropriate report to be issued following a MORPHOLOGY consultation would be:
The association of increased PLATELETS accompanying NEUTROPHILIA and TOXIC GRANULULATION as illustrated in this photograph is called THROMBOCYTHEMIA.
TOXIC GRANULATION noted in the neutrophils' CYTOPLASM reflects an increase in activity of the: (more than one answer may be correct)
Typical cells on a PERIPHERAL BLOOD SMEAR as photographed here were repeatedly encountered as the smear was reviewed. The peripheral WHITE BLOOD CELL count was 51,000/ml with an orderly matuRATIOn sequence. The comment "LEUKEMOID reaction" may properly be appended to the report.
LEUKEMOID reaction revisited
A PERIPHERAL BLOOD SMEAR with many MYELOID cells (photograph) was presented for MORPHOLOGY review. TOXIC VACUOLES in the neutrophil and MONOCYTE most likely represent:

2. LEUKOCYTOSIS Case Study

A PERIPHERAL BLOOD SMEAR is submitted for MORPHOLOGY review. The patient is a 10 year-old boy with SYMPTOMS suggesting APPENDICITIS and an appendectomy is being considered. The total WBC is 18.5 X 1000/uL, RBC's = 5.45 X 1M/uL, HEMOGLOBIN = 16.0 g/dL, HEMATOCRIT 48.2%;WBC DIFFERENTIAL: Segs = 53%, bands = 42% (two of which are shown in the photograph), MONOCYTES = 2%, and LYMPHOCYTES= 2%. These findings support the DIAGNOSIS of APPENDICITIS.
Case Follow-up
The neutrophils seen in two fields in the upper and lower photographs are representative of a majority of the left shift neutrophils found in this PERIPHERAL BLOOD SMEAR. The DIAGNOSIS of PELGER-HUET anomaly can be made.
PELGER-HUET Anomaly

3. Atypical INTRACELLULAR GRANULES

Atypical NEUTROPHILIC INTRA-CYTOPLASMIC INCLUSIONS ,as noted in the photograph, are present in a PERIPHERAL BLOOD SMEAR when one or more of the following underlying conditions are present:
CHEDIAC-HIGASHI anomaly
ALDER- REILLY Anomaly
The INCLUSIONS noted in the CYTOPLASM of this BAND NEUTROPHIL are most suggestive of:
WBC INCLUSIONS: summary
Familial disorders: summary

4. INTRA-CYTOPLASMIC INCLUSION Bodies

The PALE-STAINING CYTOPLASMIC bodies marked by the arrow in the photograph may be seen in each of the following conditions except:
Case History
DOEHLE Bodies: Review
The MAY -HEGGLIN anomaly
The CYTOPLASMIC INCLUSION illustrated at the tip of the blue arrow is characteristic of:
AUER ROD
The cell illustrated in the photograph is known as a faggot cell.

5. Miscellaneous GRANULOCYTIC Cells

The PERIPHERAL BLOOD SMEAR presented here was submitted for MORPHOLOGICAL/CLINICAL review. Conditions in which this picture may be seen include:
EOSINOPHILIA Follow-Up
EOSINOPHIL description
The GRANULATED neutrophil shown in the photograph may be found in each of the following conditions except:
The neutrophil on the PERIPHERAL BLOOD SMEAR in this photograph is a MAST CELL.
BASOPHILS

6. Non GRANULOCYTIC WHITE BLOOD CELLS

The large blue staining cells represented here in the photographs comprise 50% of the total white BLOOD count.This picture is most consistent with:
Case history
Case History 2
Approximately 10% of the CIRCULATING white cells were similar to the one seen in the photograph. The patient was 42 years old and visited his PHYSICIAN because of recent bruising. Note the absence of PLATELETS on the smear. Possible associated conditions include:
Multiple MYELOMA
A peripheral smear was submitted for MORPHOLOGY/CLINICAL because of the number of MONOCYTES as captured in the upper and lower photographs. This picture is consistent with each of the following conditions except:
The peripheral smear photographed here was submitted for MORPHOLOGIC/CLINICAL examination.The predominant cells comprised 70% of the total WHITE BLOOD CELLS and are consistent with LYMPHOCYTES in a 4 month old infant.
More about LYMPHOCYTES, their impostors and varied faces

7. MEGAKARYOCYTES and PLATELETS

PLATELET satellites (marked in the photograph) may account for low PLATELET counts as determined by electronic counters. SATELLITOSIS is initiated by:
The large PLATELET captured in the center of the photograph is indicative of disordered MEGAKARYOPOIESIS.
The PERIPHERAL BLOOD SMEAR noted in the photograph was held for MOROPHOLOGICAL and CLINICAL review as the total PLATELET count was 10,000/cumm. Conditions fitting this picture include:
The PERIPHERAL BLOOD SMEAR tagged in the photograph was held for review because of too many PLATELETS, about double the normal average of 8 - 15/OIL IMMERSION FIELD or one per 10 - 20 RBC's. Conditions in which PLATELETS are increased as noted in the photograph include:
The PERIPHERAL BLOOD SMEAR field as photographed here is representative of the smear. A machine-read PLATELET count will most likely reflect:
MEGAKARYOCYTE in BONE MARROW

8. Miscellaneous Smear Reviews

The small club-shaped(drumstick)NUCLEAR APPENDAGE attached to one lobe of a neutrophil (marked by the blue arrow in the photograph) may be found in:
The cell photographed here is known as a MOTT CELL. The condition in which these cells are associated is:
The smudge cells pictured in the photograph may be found in each of the following situations except:
The cell bulging with INCLUSIONS centered in the photograph is most consistent with CHEDIAK-HIGASHI anomaly.
A most useful follow-up test to consider when FACED with HYPERSEGMENTED NEUTROPHILS and oval MACROCYTES (see photograph) in a PERIPHERAL BLOOD SMEAR is:
ERYTHROPHAGOCYTOSIS

BONE MARROW

Normal BONE MARROW
Normal BONE MARROW Cells
The upper photograph of a BONE MARROW section reveals distinct HYPERPLASIA with total replacement of MARROW fat. A BONE MARROW smear stained with WRIGHT/GIEMSA is displayed in the lower photograph. Calculate the M:E RATIO between MYELOID and ERYTHROID cells found in the lower photograph. The total peripheral BLOOD WHITE BLOOD CELL count was 5,400/cumm. This BONE MARROW architecture may be found in each of the following conditions except:
The upper photograph of this BONE MARROW section also reveals distinct HYPERPLASIA with total replacement of the fat. The lower photograph is a WRIGHT/GIEMSA stain. Calculate the M:E RATIO of the distribution of MYELOID and ERYTHROID cells in the lower photograph. The peripheral white BLOOD count was 18,500/cumm. The most likely associated condition is:

White Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions Keywords

Click on a term below to see its use in this White Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions course and other available MediaLab courses.

blood (30 occurances)
peripheral blood smear (29 occurances)
infection (24 occurances)
leukemia (22 occurances)
granules (22 occurances)
lymphocyte (21 occurances)
toxic (20 occurances)
platelet (18 occurances)
clinical (18 occurances)
inclusion (17 occurances)
bone marrow (16 occurances)
cytoplasmic (16 occurances)
cytoplasm (14 occurances)
nuclear (14 occurances)
white blood cell (14 occurances)
monocyte (13 occurances)
syndrome (12 occurances)
ratio (11 occurances)
basophil (11 occurances)
chromatin (11 occurances)
acute (11 occurances)
eosinophil (10 occurances)
diagnosis (10 occurances)
infectious (10 occurances)
granulation (10 occurances)
chediak-higashi (9 occurances)
myeloproliferative (8 occurances)
myeloid (8 occurances)
nucleus (8 occurances)
wbc (8 occurances)
reticulum (7 occurances)
laboratory (7 occurances)
leukemoid (7 occurances)
band neutrophil (7 occurances)
differential (7 occurances)
doehle (7 occurances)
erythrocyte (7 occurances)
granulocyte (6 occurances)
azurophilic (6 occurances)
hematology (6 occurances)
myeloma (6 occurances)
myelocyte (6 occurances)
morphology (6 occurances)
vacuoles (6 occurances)
syndromes (6 occurances)
septicemia (5 occurances)
wright (5 occurances)
pelger-huet (5 occurances)
rbc (5 occurances)
reactive (5 occurances)
physician (5 occurances)
phosphatase (5 occurances)
mononucleosis (5 occurances)
may-hegglin (5 occurances)
leukocyte (5 occurances)
lymphocytic (5 occurances)
immature (5 occurances)
endoplasmic (5 occurances)
circulating (5 occurances)
cytoplasmic inclusion (4 occurances)
granulocytic (4 occurances)
giemsa (4 occurances)
erythroid (4 occurances)
albinism (4 occurances)
abnormal (4 occurances)
abnormalities (4 occurances)
anemia (4 occurances)
inflammatory (4 occurances)
hemolytic (4 occurances)
globulin (4 occurances)
hypersensitivity (4 occurances)
marrow (4 occurances)
metamyelocyte (4 occurances)
normoblast (4 occurances)
parasitic (4 occurances)
plasma (4 occurances)
plasma cell (4 occurances)
segmented neutrophil (4 occurances)
thrombocytopenia (4 occurances)
symptom (3 occurances)
vitamin (3 occurances)
stimulation (3 occurances)
red blood cell (3 occurances)
pyogenic (3 occurances)
myelogenous (3 occurances)
nuclei (3 occurances)
neutrophilic (3 occurances)
morphologic (3 occurances)
morphological (3 occurances)
myelodysplastic (3 occurances)
mucopolysaccharides (3 occurances)
monocytosis (3 occurances)
metastatic (3 occurances)
mast cell (3 occurances)
lymph (3 occurances)
hematologist (3 occurances)
hyperplasia (3 occurances)
intracytoplasmic (3 occurances)
intracytoplasmic inclusion (3 occurances)
immune (3 occurances)
lymphocytosis (3 occurances)
lysosomal (3 occurances)
leukocytosis (3 occurances)
alder-reilly (3 occurances)
alkaline (3 occurances)
bacteria (3 occurances)
autosomal (3 occurances)
asthma (3 occurances)
auer rod (3 occurances)
appendicitis (3 occurances)
cellular (3 occurances)
chediac-higashi (3 occurances)
clinician (3 occurances)
fechtner (3 occurances)
eosinophilia (3 occurances)
eosinophilic (3 occurances)
dysplastic (3 occurances)
drug (2 occurances)
enzymes (2 occurances)
corticosteroid (2 occurances)
disease (2 occurances)
diseases (2 occurances)
cutaneous (2 occurances)
epstein (2 occurances)
folate (2 occurances)
golgi (2 occurances)
cellularity (2 occurances)
appendage (2 occurances)
barr body (2 occurances)
basophilic (2 occurances)
benign (2 occurances)
bilobed (2 occurances)
body (2 occurances)
cancer (2 occurances)
carcinoma (2 occurances)
alport (2 occurances)
assay (2 occurances)
assessment (2 occurances)
autoimmune (2 occurances)
abdominal (2 occurances)
klinefelter (2 occurances)
larval (2 occurances)
hemoglobin (2 occurances)
intra-cytoplasmic (2 occurances)
intra-cytoplasmic inclusion (2 occurances)
hypersegmentation (2 occurances)
hypersegmented (2 occurances)
hypersegmented neutrophil (2 occurances)
higashi (2 occurances)
hematologic (2 occurances)
hypothyroidism (2 occurances)
identification (2 occurances)
granulated (2 occurances)
health (2 occurances)
hegglin (2 occurances)
lymphoblast (2 occurances)
malignancies (2 occurances)
macrocytic (2 occurances)
membranes (2 occurances)
metabolic (2 occurances)
megakaryocyte (2 occurances)
megaloblastic (2 occurances)
mucopolysaccharidoses (2 occurances)
morphologically (2 occurances)
mott cell (2 occurances)
myxedema (2 occurances)
neoplastic (2 occurances)
neutrophilia (2 occurances)
nonlymphocytic (2 occurances)
pseudothrombocytopenia (2 occurances)
rouleaux (2 occurances)
russell (2 occurances)
reilly (2 occurances)
protein (2 occurances)
nucleoli (2 occurances)
phagocytized (2 occurances)
serum (2 occurances)
urticaria (2 occurances)
tumor (2 occurances)
thrombocythemia (2 occurances)