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Residency - Hematopathology > Peripheral Smear Review > Flashcards

Peripheral Smear Review Flashcards

1
Q

Systematic approach to peripheral blood smear review

A

Start at the feathered edge, then the zone of holes, then the zone of morphology. Check your composition in each of these regions, since some things will only appear in the feathered edge/zone of holes.

Look at platelets first, then RBCs, then white blood cells.

Then, look for other special things (inclusions, organisms, etc).

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2
Q

When is the zone of morphology LEAST repersentative of the blood as a whole?

A

When the WBC count is over 20,000

In these cases, the feathered edge is most representative.

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3
Q

Platelet counting in the zone of morphology to approximate platelet count

A

Platelet counts of 150-400 x 10^9/L are correspond to 7-20 platelets per hpf at 1000x magnification (one 100x objective field).

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4
Q
A

Spurious thrombocytopenia

Can be caused by inadequate mixing prior to analysis, activation of thrombocytes by traumatic venipuncture, or
EDTA-dependent antibodies which agglutinate thrombocytes.

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5
Q
A

Grey platelets (agranular platelets)

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6
Q
A

RBC agglutination

May be due to infection (mycoplasma pneumoniae), LPD, or plasma cell dyscrasia. May also be idiopathic.

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7
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8
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9
Q
A

Bite cells

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10
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11
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12
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13
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14
Q
A

Schistocytes

Only call when the cells are NOT overlapping. Should lack central pallor.

Suggests microangiopathic hemolytic anemia. Required for diagnosis fo TTP or HUS, but may not be present in DIC.

Requires emergent/urgent contact of the clinical team

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15
Q

Acquired spherocytosis should make you think . . .

A

Immune-mediated hemolysis:

Autoimmune hemolytic anemia
Cold agglutinin disease
Hemolytic transfusion reaction
Paroxysmal nocturnal hemoglobinuria

Next step is DAT (direct Coombs)

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16
Q
A

Hemoglobin C disease

Often has associated poikilocytosis

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17
Q
A

Stomatocytes

Can be seen on patients taking prochlorperazine

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18
Q
A

Howell-Jolly bodies in asplenia

Sometimes seen in megaloblastic anemia or severe hemolytic anemia

Do not over-interpret the associated poikilocytosis

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19
Q
A

Pappenheimer bodies

Lysosomes containing iron-protein complexes

Also seen in asplenia, megaloblastic anemia, or severe hemolytic anemia

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20
Q
A

Basophilic stippling

Aggregated ribosomes or polyribosomes due to incomplete or impaired RNA degradation

Seen in lead poisoning, sideroblastic anemia, myelodysplastic syndrome, thalassemias, and other hemoglobinopathies

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21
Q
A

Cabot rings

Remnants of microtubules of the mitotic spindle

Seen in severe anemia

22
Q

Two main reasons to contact the clinical team immediately while reviewing peripheral smears

A

1: You see schistocytes

23
Q
A

All lymphocytes from the same patient

Note the marked variation

24
Q
A

Large granular lymphocyte

May be reactive to infection or to a tumor (including a hematopoietic tumor), may be seen in the setting of HSCT or solid organ transplant. May also represent T-LGLL or NK-LGLL.

Dasatinib therapy for Ph+ B-ALL or CML can also produce LGLs.

Use clinical judgement to consider whether or not to recommend flow.

25
Q
A

Lymphocyte cytology in the setting of infectious mononucleosis.

Hug adjacent RBCs and have peripheral basophilia. “Skirting” with blue lines radiating from the nucleus.

Recommend EBV testing.

26
Q
A

T-prolymphocytic leukemia

Characteristically have cytoplasmic blebs and prominent nucleoli.

27
Q
A

Hepatosplenic T cell lymphoma

Cells have characteristic nucleoli and adjacent perinuclear hofs.

28
Q
A

Hairy cell leukemia

29
Q
A

Mantle cell lymphoma

30
Q
A

Follicular lymphoma

31
Q
A

Lymphoplasmacytic lymphoma vs plasmacytoid change in lymphocytes, which may be seen in viral infection (such as Dengue)

32
Q
A

Chronic lymphocytic leukemia

33
Q

If you have a smear with a ton of smudge cells, what can you do?

A

Ask the lab to repeat it with an albumin preparation

34
Q

Worrisome features in monocytosis

A
35
Q

How many lobes make a hypersegmented neutrophil?

A

6+

36
Q
A

Monolobated neutrophils

Can be seen in therapy with immunosuppressants and certain antivirals:
Tacrolimus
MMF
Ganciclovir

37
Q

Ddx for neutrophil hypersegmentation

A

B12 deficiency
folate deficiency
Hydroxyurea therapy
Methotrexate therapy
Myelodysplasia

Rarely, may be a normal variant

38
Q
A

Anaplasmosis

39
Q
A

Mucopolysaccharidosis

40
Q
A

Marginal zone lymphoma cells with immunoglobulin inclusions

Look a lot like Auer rods, but the cells don’t look like promyelocytes or blasts

41
Q
A

Jordans anomaly

Seen in neutral-lipid storage disease

42
Q
A

Cryoglobulin inclusions

43
Q

Peripheral basophilia should make you suspicious for. . .

A

. . . chronic myelogenous leukemia

In CML, you will see apparent left-shift but WITHOUT reactive features (no toxic granulation, no Dohle bodies)

44
Q

Peripheral screening criteria for CML

A

WBC > 20 x 10^9/L (20,000)

Basophils > 0.2 x 10^9/L (200)

45
Q

What to do when you think you see blasts on a peripheral smear

A
46
Q

Three questions to ask yourself once you have decided there are real blasts on the peripheral smear

A
  1. Is there left-shift, or leukopenia?
  2. Are there auer rods / APML cytomorphology?
  3. Are there >20% blasts?
47
Q
A

Typical variant APML

60-70% of cases
Low WBC count
Granules and Auer rods

Weak/absent HLA-DR
Absent CD34

48
Q
A

Hypogranular variant APML

Minority of cases
Associated leukocytosis
Indistinct granules
Folded nuclei/sliding plates nuclei/butterfly nuclei

More typical APML cells usually sparsely admixed

May show dim CD34 or dim HLA-DR

49
Q

APML on flow

A

APML cells. . . can have lots of granules!

SO! They can fall in the myeloid gate rather than the blast gate!

BEWARE.

50
Q
A

Variant APML

Represents less than 5% of cases.

Lack the t(15;17) translocation.

Instead, translocations involve RARA and ZBTB16, NPM1, NUMA1, or STAT5B.

ZBTB16::RARA is the variant shown here, and has a distinct morphology. Nuclei have a more regular morphology with condensed chromatin, abundant cytoplasm, coarse granules, and fewer Auer rods.

The morphology overall looks more myelocytic. So, you have to have a high index of suspicion to look for alternative RARA translocations.

Residency - Hematopathology (21 decks)

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