Blood Smear Findings Research Articles

Erythrocyte T-antigen activation in children: Patient characteristics and the hemolytic risk of transfusion.

T-antigen activation usually occurs upon red blood cell (RBC) membrane cryptantigen exposure due to bacterial enzymes. Although uncommon, the condition is probably underrecognized. There is concern about hemolysis after plasma and plasma-containing platelet transfusions due to naturally occurring anti-T antibody in healthy blood donors. However, experts have debated the extent and severity of clinical hemolysis due to anti-T. We retrospectively identified patients who tested positive for polyagglutination with Arachis hypogea and Glycine max lectins from 2008 to 2019. The records of the patients were reviewed to determine clinical symptoms, laboratory evidence of hemolysis, need for transfusion, and clinical outcomes. Ten patients were identified. At diagnosis, all were anemic and four had thrombocytopenia. Severe Streptococcus pneumoniae infection affected seven patients; one died. Seven of 10 patients (70%) had laboratory evidence of hemolysis. Peripheral blood smear findings in six patients included RBC agglutination and changes suggesting hemolysis (spherocytes and schistocytes), but three had unremarkable RBC morphology. Four patients required plasma or platelet transfusions; all survived to discharge. T-antigen activation is a rare entity. Most patients diagnosed at our hospital had hemolytic anemia and severe pneumococcal infection. Hemoglobin decreased after plasma and platelet transfusions in all patients assessed, but these transfusions were necessary to support treatment. RBCs were given to maintain appropriate hemoglobin levels.

Scattergram Patterns of Hematological Malignancies on Sysmex XN-Series Analyzer

BACKGROUND: Automated hematology analyzers effectively reduce turnaround time and generates scattergrams which can be used to screen for different hematological conditions. AIMS: We wish to study the scattergrams generated by the Sysmex XN-series analyzer for confirmed cases of hematological malignancies and evaluate for the specific patterns to these malignancies. METHODS: Two hundred and ninety-one newly diagnosed cases of various hematological malignancies were included in the study. All these cases were diagnosed and classified in accordance with flow cytometry, bone marrow morphological study, immunohistochemistry, and molecular studies. Forty-eight cases of leukemoid reaction were also included in the study. We retrieved the scattergrams and complete blood count data of all these cases which were processed in the Sysmex XN-analyzer before their diagnosis. Along with scattergrams, the peripheral blood smear findings of all the cases were extracted too. The scattergram patterns in the white blood cell differential (WDF) and white cell nucleated region (WNR) channels were evaluated and correlated with their peripheral blood smear findings. RESULTS: All the scattergrams in the WDF and WNR channels were studied. Patterns seen in acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) were striking and distinctly separate. After correlating with the peripheral smear and immunophenotyping, AML patterns were subtyped by the French American British classification. Acute promyelocytic leukemia as well as different phases of chronic myeloid leukemia had unique patterns. Scattergram patterns of ALL had minute difference with that of chronic lymphoproliferative disorder. CONCLUSION: In high-volume laboratories, the patterns on Sysmex XN-series analyzer scattergrams can be used as a valuable aid for suspecting and triaging cases of hematological malignancies.

Study of peripheral blood smear findings in patients of anemia and to compare it with automated hematology analyzer generated red cell parameters

Introduction: Anemia is one of the common medical conditions prevalent in our society. The correct categorization of varying types of anemia is essential for therapeutic purposes. Various laboratory tests are done to find out its underlying cause, but peripheral smear (PS) study of red blood cells (RBCs) morphology is important along with study of red blood cell indices in the classification of anemia.
 Objectives: This study was done to evaluate RBC morphology on peripheral smear examination in patients of anemia and to compare these findings with cell counter generated red blood cells indices comprising of Mean corpuscular volume (MCV), Mean corpuscular hemoglobin concentration (MCHC) and Mean corpuscular hemoglobin (MCH)
 Methodology: Red blood cell morphology on peripheral blood smear was studied in 350 patients of anemia irrespective of age and gender received under six months duration from 1st January 2019 to 30 th June 2019 and findings were compared with cell counter generated red cell parameters generated by automated hematology analyzer.
 Results: Most common anemia seen on smear examination was microcytic hypochromic anemia which accounted for 210 (60%) cases followed by dimorphic anemia in 73 (20.86%) cases. Most of the patients were female, comprising of 227 (64.85%) cases. Highest numbers of patient were in the age group of 21-30 years (20.30%). Sensitivity of MCV was 78%, MCHC was 14% and MCH was 80% in detection of microcytic hypochromic anemia. The sensitivity of MCV and MCH was found to be 100 % in detection of macrocytic anemia. Sensitivity of MCHC was only 10% for detection of macrocytic anemia. The sensitivity of MCV, MCHC and MCH was 78%, 100% and 67 % respectively in detection of normocytic normochromic anemia. 
 Conclusion: The peripheral smear examination should always be interpreted along with the red blood cell indices generated by an automated analyzer in order to classify various types of anemia.

Peripheral Blood Smear Findings in COVID-19

Peripheral Blood Smear Findings in COVID-19

A novel SPTB gene mutation in neonatal hereditary spherocytosis: A case report.

The aim of the present study was to enhance the understanding of the diagnosis and treatment of neonatal hereditary spherocytosis (HS). Gene sequencing and analysis was performed for the crucial splicing signals on the exons and introns of the 302 known pathogenic genes [including ANK1, SPTAN1, SPTA1, EPB42, SLC4A1, and SPTB] that are associated with this genetic deficiency of erythrocytes. A 26-day-old female presented with jaundice, anemia, an increased count in peripheral blood reticulocyte and spherocytes and a positive acidified glycerol hemolysis test. Gene sequencing revealed a novel mutation of c.3737delA (p.Lys1246fs) in the exon 16 of SPTB (14q23|NM_000347.5) gene in the patient and her father. The mutation was a frame-shifting mutation, which may result in the truncation of β-haemoglobin in the erythrocyte membrane can lead to loss of normal function, leading to the occurrence of diseases, including jaundice and hemolytic anemia. For neonates with jaundice and anemia, family history, erythrocyte index and peripheral blood smear findings have been indicated to contribute to the diagnosis of HS. In the current study, gene sequencing was indicated to be helpful for the diagnosis of HS. A novel mutation of SPTB gene was identified, which may be pathogenic via modulating the activity of β-spectrin in the erythrocyte membrane.

Assessment and reliability of suspect flags in automated hematology analyzers for diagnosing white blood cell and platelet disorders

Background: The automated hematology analyzers have replaced the traditional manual methods for assessing hematological parameters. Most of the automated hematology analyzers are programmed to identify abnormalities in the form of “suspect flags.” Aims: The aim of the study was to correlate white blood cell (WBC) and platelet (PLT) flag messages provided by automated analyzers with their respective peripheral blood smear (PBS) findings. Materials and Methods: A descriptive cross-sectional study was undertaken on 100 patients who showed WBC and PLT suspect flags and/or abnormal peripheral smears. The flag messages were analyzed with their respective PBS findings. Pearson's Chi-square test was used for the statistical analysis. Results: Analyzer and PBS showed WBC defects (n = 46, 32), PLT defects (n = 39, 54), and combined defects (n = 36, 43) respectively. WBC defects included leukocytosis (n = 27, 22), leukopenia (n = 20, 18), immature granulocytes (n = 10, 3), left shift (n = 3, 2), myeloblast blast (n = 2, 1), and eosinophilia (n = 4, 4) on analyzer and PBS. Correlation between the WBC suspect flags and their peripheral smears was found to be statistically significant (P = 0.006). PLT defects included thrombocytopenia (n = 22, 30), thrombocytosis (n = 13, 17), giant PLTs (n = 10, 15), PLT clumps (n = 8, 12), and PLT debris (n = 2, 5) on analyzer and PBS. Correlation between the PLT characteristics in analyzers and in peripheral smears was statistically significant (P = 0.042). Conclusion: Suspect flags should be used as a screening tool to pick up pathological samples. These should then be followed up with a PBS examination for definitive diagnosis.

CLINICAL ASSESSMENT OF PANCYTOPENIA IN PERIPHERAL BLOOD SMEARS IDENTIFIED IN PATIENTS FROM BIHAR REGION

The severity of pancytopenia and the underlying pathology determine the management and prognosis. [3] Thus, identification of exact cause will help in implementing appropriate therapy. The major diagnostic problems occur when there are no specific features in the peripheral smear to point the cause. In India the causes of pancytopenia are not well defined, so the present study has been undertaken to evaluate the various causes and to correlate the peripheral blood smear findings.
 The present study was planned in Department of Pathology, Anugrah Narayan Magadh Medical College, Gaya, Bihar from july 2017 to Dec 2017. Total 50 cases of the clinical suspicion of a hematological disorder and demonstrating pancytopenia in the peripheral blood smears were enrolled in the present study.
 All participants underwent a detailed history, clinical examination and investigations which included complete blood picture with red cell indices and peripheral smear, liver function test, renal function test, ultrasound abdomen and bone marrow examination in all cases. Cause of pancytopenia was ascertained and data was analysed on SPSS on the basis of etiology, clinical and haematological findings.
 The data generated from the present study concludes that systematic and thorough workup is required in patients presenting with pancytopenia, so that elimination of the cause is needed to treat the condition. Among them, megaloblastic anaemia and infections are early treatable and reversible.
 Keywords: Pancytopenia, Bone Marrow Aspiration, Megaloblastic Anemia, Hypo plastic Marrow, etc

A prospective study of hospitalized patients with leukemoid reaction; causes, prognosis and value of manual peripheral smear review.

Several diagnoses have been associated with leukemoid reaction (LR). In patients with LR the diagnostic and prognostic value of detailed manual blood smear counts (such as the percentage of band cells or grading of neutrophil toxic changes) has not been studied previously. We prospectively recorded all hospitalized adult (> 18 years old) patients with LR (≥ 30000/ul) of neutrophilic predominance, excluding patients with pre-existing leukocytosis due to hematological malignancies. We examined the diagnoses and prognosis (in-hospital mortality and post-discharge mortality up to a year after the end of the study) of these patients as well as the value of manual peripheral smear review. We recorded a total of 93 patients with LR from January 2017 to December 2017. Infection was the most common diagnosis (70%), followed by malignancy (7.5%) and bleeding (6.5%). In-hospital mortality (45%) and post-discharge mortality (35% of those discharged) were very high. Among blood smear findings, only neutrophil vacuolation was significantly more common in patients with infections (34%), although it was also observed in many patients without any infection (13%). Blood smear findings were not associated with prognosis. Detailed manual smear review is a labor-intensive procedure and it has limited diagnostic and prognostic value in unselected hospitalized patients with neutrophilic LR.

Comparison of Different Small Clinical Hematology Laboratory Configurations With Focus on Remote Smear Imaging.

Stand-alone clinical sites (eg, infusion centers) are becoming increasingly common. These sites require timely hematology analysis. Here we compare performance and costs of currently available analysis configurations with special focus on a proposed alternative using a minimal hematology analyzer plus a digital imaging device, allowing for remote oversight and interpretation. To determine whether low-volume laboratories might realize savings while gaining function by substituting commonly used configurations with a proposed alternative. To evaluate the performance of the proposed alternative configuration, blood counts with automated differentials produced by a Sysmex XE5000 (complete blood count reference method) were compared with cell counts from the Sysmex pocH-100i, CellaVision DM96 preclassified differentials, and DM96 reclassified differentials (differential reference method) by using standard regression analyses, 95% CIs, and truth tables. Financial cost modeling used staffing practices, test volumes, and smear production rates observed at remote clinics performing on-site hematology analysis within the University of California at San Diego Health system. Differential blood count parameters showed excellent correlation between the XE5000 and preclassification DM96 with R2 > 0.95. For blasts/abnormal cells, immature granulocytes, and nucleated red blood cells, the DM96 showed higher sensitivity and similar specificity to the XE5000. Cost modeling revealed that decreased personnel costs through remote monitoring of results facilitated by the DM96 would lead to lower operational costs relative to more conventional analysis configurations. A digital imaging instrument with an inexpensive hematology analyzer provides similar information to a complex hematology analyzer and allows remote review of the blood smear findings by experts, leading to significant cost savings.

A Clinico-Hematological Study of Cases of Leucoerythroblastic Reaction

Background: Leucoerythroblastic Reaction (LER) is defined as the presence of immature red cells and immature white cells of the myeloid series in peripheral blood. Literature has revealed various causes for LER, which include hemolyticanemia, infections, megaloblastic anemia, liver diseases and others. Objectives: To study the hematological changes, especially peripheral blood smear (PBS) findings in LER cases. Methods: A total number of 100 consecutive cases which revealed LER on peripheral blood smear (PBS) were included in this study. Various hematological parameters such as. hemoglobin, total leucocyte count, platelet count as obtained from the automated blood cell counter and PBS findings were analysed. Results: In the present study, majority of the cases (30%) were in the age range of 21 to 30 years, with equal gender distribution. Anemia was seen in 87% of the cases, leucocytosis in 79% and thrombocytopenia in 60%. Polychromasia with increased reticulocytes was noted in 55% of the cases. Nucleated RBCs were noted in all cases. All cases showed shift to left in the myeloid series. Commonest cause of LER encountered was hemolytic disease (29%) followed by liver diseases (22%) and septicemia (18%). Conclusion: The present study emphasizes various etiologies of LER and the importance of reporting LER in PBS. Examination of peripheral blood smear for morphology of RBCs, WBCs and platelets gives a clue to the etiology.

Case 2: A Patient with Trisomy 21, Transient Abnormal Myelopoiesis, and Pneumoperitoneum

A 34-week-gestation male infant is born appropriate for gestational age to a 41-year-old gravida 3, para 3 woman. The patient’s mother had received limited prenatal care starting at 15 weeks, and is found to have a positive result on maternal serum α-fetoprotein screening test and an amniocentesis that confirms trisomy 21 (47,XY+21 karyotype) with no evidence of translocation or mosaicism. The infant is born at an outside hospital and has physical features characteristic of trisomy 21. He is transferred to our facility for respiratory distress and multiple episodes of apnea and bradycardia on the day of birth. Sepsis is ruled out on admission. His initial complete blood cell count is significant for a white blood cell count of 15,300/μL (15.3×109/L) with 25% blasts. He is also noted to have an enlarged liver that is 1 cm below the costal margin. Peripheral blood smear and flow cytometry findings are consistent with a diagnosis of transient abnormal myelopoiesis (TAM). Pediatric hematology is consulted and recommends complete blood cell counts which are obtained regularly until day 22 after birth, when the TAM spontaneously resolves. The infant is able to receive full enteral feedings until he develops abdominal distention and irritability on day 12 after birth. An abdominal radiograph is notable for pneumoperitoneum concerning for an acute bowel perforation without signs of …

The utility of peripheral blood smear review for identifying specimens for flow cytometric immunophenotyping.

Laboratory professionals are in an ideal situation to identify CBC and peripheral blood smear findings that raise the possibility of a hematolymphoid neoplasm, and based on this information make recommendations for additional studies, such as flow cytometric immunophenotyping. In some circumstances a definitive diagnosis can be established from the combined peripheral blood morphologic and immunophenotypic findings obviating the need for bone marrow evaluation, such as for chronic lymphocytic leukemia. Occasionally flow cytometric studies are superior to morphologic assessment, such as in screening for hairy cell leukemia or identifying lymphocytic-variant hypereosinophilia. However, there is increasing recognition of small immunophenotypically unusual or abnormal populations of peripheral blood cells, particularly in older patients, which are of uncertain clinical significance, such as monoclonal B lymphocytosis and T-cell clonopathy. Therefore, it is important to integrate peripheral blood smear review findings with the clinical and other information before recommending flow cytometry. In addition, it is important to recognize situations where the results of peripheral blood smear review and flow cytometric immunophenotyping do not explain the clinical findings.

Coinheritance of Hereditary Elliptocytosis and Deletional Hemoglobin H Disease

Hereditary elliptocytosis is an inherited red blood cell membrane disorder characterized by typical peripheral blood smear findings of elliptocytes or rod-like red blood cells. Hemoglobin H disease is a form of α-thalassemia disease resulting in mild to moderate hemolytic anemia. The authors report 1 case of a girl who was diagnosed with oculo-auriculo-vertebral spectrum and a coinheritance of hereditary elliptocytosis and deletional hemoglobin H disease. She had moderate, non-transfusion-dependent anemia. The red blood cells showed marked poikilocytosis and fragmentation. The parents were α-thalassemia carriers and the father had the typical red blood cell morphology of common hereditary elliptocytosis.

Minimal Hematology Analyzer Plus Blood Smear Digital Imaging/ Analysis Provides Better Clinical Hematology Results Than a Complex Hematology Analyzer Alone

Introduction: Devices such as the CellaVision® DM96 (CellaVision AB, Lund, Sweden) locate and image nucleated cells on blood smears. Using image recognition software, the DM96 also pre-classifies those cells into differential categories similar to the most complex hematology analyzers. We compared the cell counts, differential counts and flagging information gained from a complex hematology analyzer, the XE5000 (Sysmex, Kobe, Japan), with information from a minimal hematology analyzer (Sysmex PocHi) plus the DM96. We found that the cell counts, differential and flagging capabilities are similar, but the PocHi plus DM96 advantages include allowing remote review of the blood smear.Methods: 210 blood samples, selected for various abnormalities, had complete blood counts with automated differentials produced by a Sysmex XE5000 hematology analyzer. These results were compared with cell counts from the Sysmex PocHi hematology analyzer, their 100-cell DM96 post reclassification differentials, and with DM96 pre-classification differentials using standard regression analyses and Rumke 95% confidence intervals (CI) as calculated using the Clopper-Pearson method. Flagging by the XE5000 for immature granulocytes (IG’s) and for blasts/abnormal cells was compared to the DM96 pre-classification using truth tables with the DM96 post reclassification as the gold standard. The following translations were used to compare flagging: IG’s > 2 for either post reclassification DM96 differential, XE5000 or the DM96 pre-classification differential; Any blast cells on the manual differential were compared to XE5000 flags WBC Abn Scg; NRBC Abn Scg; Blasts?; Atyp LY?; Abn Ly/ L_Bl? and to DM96 pre-classification % Blasts > 0%; unidentified cells >3%. .Results: Non-differential blood count parameters including white blood count, red blood count, hemoglobin, mean corpuscular volume (MCV), and platelet count showed excellent correlation between the PocHi and the XE5000 with R2>0.95. Differential-dependent blood count parameters including neutrophils, lymphocytes, monocytes, eosinophils, basophils and immature granulocytes showed excellent correlation between the XE5000 and pre-classification DM96 with R2>0.95. Nucleated red cells also showed excellent correlation between the XE5000 and the DM96 with R2>0.85.For blasts/abnormal cells, the DM96 showed 100% sensitivity and 40% specificity with 0% false negatives. The XE5000 showed 93% sensitivity and 19% specificity with 3% false negative. Two of the false negatives were shared by both instruments and were 1% blasts. Of the three false negatives with the XE5000 that were true positives with the DM96, two had 1% blasts while one had 2% blasts. For immature granulocytes (IG’s), the XE5000 showed 94% sensitivity and 79% specificity with 2% false negatives. The DM96 showed 85% sensitivity and 95% specificity with 4% false negatives. All of the false negatives were for IG’s < 5%Conclusions: Pairing the DM96 or a similar imaging instrument with a relatively inexpensive hematology analyzer, such as those commonly used in physician office laboratories, would provide all of the information available from expensive, complex hematology analyzers in high throughput laboratories AND allow remote review of the blood smear findings by experts. DisclosuresBroome:CellaVision: Consultancy, Research Funding. Bengtsson:CellaVision AB: Employment, Equity Ownership. Palm:CellaVision: Employment, Equity Ownership.

Intraoral ecchymosis in myelodysplastic syndrome with myelofibrosis: A case report

Myelodysplastic syndrome (MDS) with myelofibrosis having intraoral manifestations as ecchymosis, unprompted gingival bleeding, and generalized gingival overgrowth with associated periodontal disease is one of the rare cases. MDS is a clonal disorder of pluripotent hematopoietic stem cells. Myelofibrosis is a disorder where normal bone marrow is replaced with a fibrous scar tissue. It is a complication of MDS. Here, we are discussing a rare case report of MDS with myelofibrosis manifesting as intraoral ecchymosis. MDS with myelofibrosis is aggressive disorder of elderly whose pathophysiology remains unknown with a poor prognosis. When myelofibrosis is observed in a bone marrow specimen, further investigation of the patient with respect to splenomegaly, leukocyte count, peripheral blood smear and bone marrow findings, and karyotype will serve as a guide to correct diagnosis.

Genotype-Phenotype Correlations in Hereditary Elliptocytosis (HE) and Hereditary Pyropoikilocytosis (HPP)

▪Hereditary elliptocytosis (HE) results from defects in the erythrocyte membrane proteins α-spectrin, β-spectrin or protein 4.1R that weaken the ÒhorizontalÓ cytoskeletal associations causing decreased mechanical stability and deformability of the red blood cell (RBC). The hallmark of HE is the presence of elliptical RBCs on peripheral blood smears. Diseases within the spectrum of HE include classic HE and hereditary pyropoikilocytosis (HPP). The traditional diagnosis of HE relies on visualization of elliptocytes on the blood smear, while HPP is characterized by significant poikilocytosis and abnormally shaped RBCs. In vitro assessment of RBC membrane biomechanical properties using ektacytometry is characteristic. However, this evaluation requires a pure RBC population, which may not be available in patients requiring frequent transfusions and does not predict disease course or severity.Using a Next-Generation sequencing panel for 12 genes associated with RBC membrane disorders, we identified the causative genetic mutations in 8 patients with clinically diagnosed or suspected HE or HPP (3 with HE and 5 with HPP). We correlated the identified genetic mutations with clinical presentation, blood smear findings, and ektacytometry results.HE patients: 2 patients with HE had heterozygous mutations in SPTA1 (p.L154_L155insL) resulting in spectrin self-association defect, while the third one had a novel nonsense heterozygous mutation in EPB41 (p.R262*) resulting in defective horizontal interaction between spectrin and actin in the RBC cytoskeleton due to decreased band 4.1R. The same novel mutation was identified in the patient's mother. Both, the patient and the mother, had smear findings and ektacytometry profiles consistent with the diagnosis of HE (Fig. 1A).HPP patients: 3 out of 5 HPP patients were found to be compound heterozygous for a SPTA1 mutation at the self-association site (p.R28H or p.L154_L155insL) and a low-expression SPTA1 allele (c.6531-12C>T known as α-LELY or Low Expression LYon) which allows for the expanded expression of the HE-causing mutation located in trans, resulting in a more severe phenotype. Of note, two siblings carried the same SPTA1 mutation (p.L154_L155insL); one was heterozygous and had mild HE while the other sibling carried α-LELY in trans to the HE-mutation causing a more severe anemia with poikilocytosis and worsened deformability consistent with HPP (Fig. 1B). The ektacytometry profile of these two siblingsÕ RBCs demonstrates the role of α-LELY in modifying the phenotype of elliptocytic disorders. A fourth patient with HPP was found to have compound heterozygosity for mutations in SPTA1 (p.L154_L155insL) and SPTB (p.W2024R) both in the self association sites between α- and β-spectrin. The fifth patient was a 3 y.o. boy with transfusion-dependent hemolytic anemia since infancy and therefore his erythrocyte phenotype could not be evaluated. He was homozygous for a novel mutation in SPTB (p.F2014V); both of his parents were heterozygous for the same mutation. The parents were asymptomatic but their ektacytometry profiles and blood smears were consistent with HE (Fig. 1C), indicating that this mutation in the b-spectrin dimerization domain alters the α- and β-spectrin interaction causing HE in heterozygous state and HPP in the homozygous state.Next-Generation sequencing for genetic diagnosis in HE and HPP can confirm or identify the diagnosis and may be helpful to predict the phenotype and clinical severity in these heterogeneous disorders. Combining clinical data, ektacytometry and family studies is important to understand the relevance of new genetic variants to pathology of RBC cytoskeletal disorders, provide insight into the genotype-phenotype correlation, and improve the genetic counseling and clinical care for these disorders.Figure1. Ektacytometry profiles of : A) a patient and his mother heterozygous for a novel nonsense mutation in EPB41 (p.R262*) causing HE, B) a patient with SPTA1 mutation (p.L154_L155insL) and α-LELY causing HPP compared to a sibling with the same heterozygous mutation in SPTA1 without α-LELY causing HE, C) novel mutation in SPTB (p.F2014V) causing mild HE to heterozygous parents but severe transfusion-dependent anemia in the homozygous child. Ektacytometry was not performed in the child since he was chronically transfused. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Gram Negative Bacteremia Diagnosed on Peripheral Blood Smear Examination

Septicemia is a severe clinical syndrome characterized by systemic signs of infection, shock and systemic organ failure. Hence a rapid and definitive diagnosis is mandatory for proper management. Diagnosis of sepsis is routinely confirmed by presence of organisms in blood or at the site of infection which is usually done through culture which is a time consuming method and hence does not play much role in the initial treatment decision. In such scenario microscopic examination of peripheral blood can be of great help to hasten the confirmation of septicaemia, thereby enabling doctors to immediately select a more specific therapy [1-3]. Although several species of bacteria have been described on examination of peripheral blood smears but bacteremia due to gram negative rods has rarely been reported [1, 4-6]. We describe an interesting case of a 28-year-old female who presented with high grade fever which was associated with chills, vomiting, and loss of appetite and generalized weakness. Hematological examination revealed presence of anemia (hemoglobin 9.0 g/dL), leucocytosis (total leucocyte count 26.7 × 103/μL) and thrombocytopenia (62 × 103/μL). Peripheral blood smear (PBS) examination showed neutrophilia (absolute neutrophil count of 21.89 × 103/μL) and presence of shift leucocytes. Apart from these features, toxic vacuolizations were seen in the neutrophils along with frequent presence of intracellular structures which were uniform and rod shaped, suggestive of phagocytised bacilli. Similar bacilli were also seen lying extracellular in small and large clusters (Fig. 1). Gram stain of peripheral blood affirmed the presence of gram negative bacteremia. Later the blood culture confirmed the blood smear findings and revealed presence of Pseudomonas aureginosa. The patient’s condition kept on deteriorating and 2 days after admission, the female developed multi-organ failure and succumbed to her disease in spite of intensive medical treatment. PBS has never been a popular diagnostic tool for septicemia due to certain limitations. Firstly, it is less sensitive technique as detection of microorganism requires a concentration of 105 CFU/mL or greater which is unusual [7, 8]. And secondly, it is the inability to identify the species of microorganism. For these reasons, this method is mainly limited for identification of parasitic organisms in diseases like malaria and filaria. Nevertheless this limitation can be overcome to certain extent. Sensitivity could be increased by using buffy coat along with increasing experience and sufficient training of laboratory observers [9]. Also typical gram reaction, morphologies and arrangements of the observed organisms may help in presumptive identification of certain etiological bacteria [10]. During PBS examination for bacteria certain points should be kept in mind. The organism should be intracellular and the cells containing them must be leucocytes. Associated finding like toxic granules, vacuoles and Dhole inclusion bodies in neutrophils are also very predictive of systemic infection. Presence of only extracellular microorganism should be reported with special care as it may represent contamination [11]. Thus to conclude, simple, inexpensive and safe PBS examination should be more widely used especially when overwhelming bacteremia is suspected in conditions like hyposplenism, AIDS neonatal sepsis, etc. In such scenario, it can prove to be an important tool to provide rapid preliminary diagnosis, thereby allowing clinicians to strengthen the empirical anti-microbial regimen.

Bone-marrow spectrum in a tertiary care hospital: Clinical indications, peripheral smear correlation and diagnostic value

Aim: The aim was to identify the indications for a bone-marrow aspiration study, to correlate between peripheral blood smear findings and those of bone-marrow aspiration; and to assess the diagnostic value of bone-marrow aspiration examination. Settings and Design: A retrospective study was done on patients referred for bone-marrow aspiration in a tertiary care hospital for a period of about 3 years. Materials and Methods: Stained bone-marrow aspirate smears were examined. Records regarding the clinical indication for the procedure, peripheral blood smear reports, blood counts and significant findings on bone-marrow aspiration examination were retrieved. The role of bone-marrow aspiration in the diagnosis of hematological and nonhematological disorders was reviewed in the study. Results: Of a total of 153 cases, 24 (15.68%) were from the pediatric age group and 129 (84.32%) were adults. Male:female ratio was 1.3:1. The indications were anemia for evaluation (33%), evaluation of pancytopenia (26%), suspicion of malignancy (17%), fever (10%) and thrombocytopenia (3%). Bone-marrow aspiration yielded a diagnosis of hematological malignancy in a total of 11 cases. However, peripheral blood smear examination was able to pick up only seven of these cases. Furthermore, one case of metastatic deposits was seen in a case of carcinoma of unknown primary. The bone-marrow findings correlated with the peripheral blood smear findings in 54 (43.2%) out of 125 of the total cases. Conclusion: This study shows that bone-marrow aspiration is a valuable diagnostic tool and aids in diagnoses and etiology of various hematological findings such as anemia and pancytopenia.

Severe Hemolysis in Systemic Loxoscelism

Introduction: Brown recluse spider bites are encountered commonly in endemic areas of North and South America. Loxosceles reclusa is the species of Loxosceles most commonly seen in the states of MO, KS, OK, TX, AK, LA, KY, TN, MS, AL and parts of IL, IA, IN and GA. The incidence of hemolytic anemia with systemic loxoscelism in the USA seems to be significantly higher and more severe than the incidence and severity reported in studies from South America (13%-15% incidence). In our 6 cases of loxoscelism associated with severe hemolysis, we noticed that there are signs and symptoms that could be helpful to guide the follow up and facilitate early diagnosis.Method: We reviewed 6 cases of hemolytic anemia from Loxoscelism treated at the University of Missouri Hospitals. Of these 6 cases 4 were treated within 1 year. All of the cases presented with systemic and cutaneous manifestations. Each patient was initially treated symptomatically and discharged without a close follow up. This resulted in delayed presentations with symptoms of severe hemolytic anemia associated with significant morbidity [Syncope (1), Syncope with fracture (1), Hypotension needing ICU care (1), Necrotizing fasciitis (1), and severe hepatosplenomegaly with hyperbilirubinemia (1)]. We have summarized the systemic symptoms, peripheral blood smear and laboratory findings that correlate with hemolytic anemia.Results:Patients presented with Nausea (6/6), Vomiting (5/6), Fever (5/6), and Target lesion (6/6) within 48 hours after spider bite [Table 1]. Severe hemolysis developed at a median of 6.5 days after the spider bite. DAT was positive for IgG and C3 in all of the cases. Peripheral smear findings included leukocytosis with toxic granulations, Dohle bodies and left shift, Nucleated RBC, anisopoikilocytosis with some schistocytes, hemophagocytosis and normal to decreased platelets [Figure 1] [Figure 3]. When not recognized patients presented with sudden and severe hemolysis (median drop in Hb =7.5 g/dL) [Table2] resulting in hospitalization with severe morbidity (Figure 2).Table 1Initial PresentationSignificant MorbidityPatient 1Nausea and vomiting. Fever. Diffuse rash, RUQ pain Target lesion on backSevere Jaundice Hepatomegaly SplenomegalyPatient 2Nausea, vomiting and diarrhea. Fever Target lesion on left armSyncope Ankle fracturePatient 3Nausea, fatigue and malaise. Target lesion on right backRecurrent syncopePatient 4Nausea, Vomiting Fever Target lesion right arm.Severe Hypotension ICU carePatient 5Nausea, dry heaves Fever. Thigh pain Target lesion right thigh.Necrotizing fasciitis FasciotomyPatient 6Nausea, vomiting and fatigue. Fever. Target lesion right shoulder. [Display omitted] [Display omitted] [Display omitted] Table 2Patient 1Patient 2Patient 3Patient 4Patient 5Patient 6MedianAge34312125212223.5Days after bite to lowest Hemoglobin8566796.5Baseline Hb (g/dL)1112151313.815.713.4Lowest Hb (g/dL)5.74566.68.45.85MCV with lowest Hb (fL)701071009096.610198.3WBC (103/µL)12.64232.314.533.426.629.45Platelets (103/µL)16014123464261576197LDH (unit/L)hemolysed20809511348744346951T. Bili (mg/dL)35.413.251.83.77.4D. Bili (mg/dL)>109.2.3.50.31.4Ind. Bili (mg/dL)3.94.7AST (unit/L)1005225201120156ALT (unit/L)86951991104294Alk phos (unit/L)94886736160159Blood groupA PosA PosO PosB PosO PosDiscussion: Systemic loxoscelism from Loxosceles reclusa in USA is associated with a high incidence of severe hemolytic anemia. Increased awareness of the delayed presentation with hemolysis after initial signs of systemic loxoscelism could avoid life threatening events. Initial symptoms developed within 48 hours of the spider bite and led to medical attention in all of the reported cases.With appropriate follow up, peripheral smear review and labs at 5-7 days after the spider bite most of the cases would have been recognized early and could have potentially avoided life threatening complications.The different species of Loxosceles prevalent in South America could explain the difference in the incidence of hemolytic anemia. Studies from Brazil have reported the use of antivenom in about 50% of loxoscelism cases. Effectiveness of antivenom is not established and is seldom used in the USA but, could account for some differences in the incidence of hemolysis. DisclosuresNo relevant conflicts of interest to declare.

Declined Presentation: Peripheral blood smear findings in burn patients

Microscopic examination of peripheral blood films plays an important role to supplement the information by automated hematology analyzers. Various hematologic changes were reported after burn injury. In this study, we examined the peripheral blood smears and investigated the characteristics in burn patients.