A Hematology Case Study

about Leukemia by

Sarah Wycoff

ALL in a Days Work…ALL in a Days Work…

Questions to Consider:

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

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

Patient History 50-year-old female No prior medical problems Admitted to ER with chest pain,

fatigue and shortness of breath

CBC and Differential ResultsWBC: 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)

Peripheral Blood Smear Normal

lymphocyte in the middle

4 blast cells in the corners

Bone Marrow Aspirate Cellularity is

increased at 95-100%

Normal hematopoietic marrow is replaced by an immature lymphoid infiltrate

Normal Bone Marrow

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)

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)

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)

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

ALL subtypesT-Cell - 20-25%Precursor B-cell (L1 and L2) – 70-75%Mature B-cell (Burkitt – L3) – 5%

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 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 Chemotherapy with

Cyclophosphamide, Mesnex, Viacritine, Doxorubican and Decadron

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

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 Consider1) Blasts have a higher nucleus to

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

2) Cytochemical stains used to diagnosis Acute Lymphocytic Leukemia:

• MPO negative• SBB negative• PAS positive

CreditsThis 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.