Evaluation Of Peripheral Blood Smears Research Articles

Decision support system for the classification of Downey cells as a pre-diagnostic tool

Abstract Objectives Epstein–Barr virus (EBV) is a member of the herpes virus that causes infectious mononucleosis (IM). Downey cell is the atypical lymphocyte of IM and can be seen in various conditions. Peripheral blood smear (PBS) microscopic evaluation is used to identify Downey cells. A lack of experienced professionals or professional errors may obstruct early and accurate diagnostics for the microscopic evaluation. The main objective of this study is to create a decision support system by digitizing the PBS samples. A general tool providing an inexpensive and measurable solution is envisioned to analyze the PBS samples in detail to give alerting flags to prevent missing Downey cells in manual analysis. Methods The PBS dataset collected was split into Downey positives and negatives. The negative set consisted of 5 leucocyte subtypes. Mantiscope, a cloud-based slide scanner system, was used to collect images from the physical PBS samples. Clinically and laboratory-confirmed 35 IM patients and 124 healthy PBS slides were selected for this procedure. A number of cell counts were obtained after the application of annotation and augmentation methods, and a partially balanced dataset was created for the artificial intelligence (AI) network training. The verification steps included the calculation of sensitivity, specificity, and Cohen’s kappa metrics from the partitioned testing set that was not used during training. A validation process was also performed over the manually identified PBS samples to measure whether the algorithm noticed the samples or not. Results After testing this setup, we have observed 98 % sensitivity and 99 % specificity for Downey cells. According to the validation procedure of Downey positive and negative samples that were carried out by the physicians, a sensitivity of 57 %, specificity of 100 %, and Cohen’s kappa value of 0.5 were observed. Besides, the accuracy was found to be 66 % according to the physicians’ evaluations employing the digital images which were identified by Mantiscope, Conclusions Decision support systems can alert the physician for Downey cells and increase the rate of true diagnosis in PBS evaluation. A higher sensitivity and specificity for the detection of Downey cells would be achieved. However, the variance over the dataset is a constraint for effective diagnosis. As the annotation and AI development process continues to collect more data from patients, the model can be updated for future releases.

THE ACUTE LYMPHOBLASTIC LEUKEMIA OF DOWN SYNDROME

Down syndrome (DS) is a genetic disorder caused by the presence of a third copy of chromosome 21.It is usually associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features .Children with DS are at an elevated risk of leukemia, especially myeloid leukemia. On the other hand, children with DS are at a 20-fold increased risk for acute lymphoblastic leukemia (ALL).In our case, we presented a patient with DS who was diagnosed with ALL. 19-year-old male was admitted to the emergency department due to abdominal pain.On his physical examination,splenomegaly was detected.In laboratory examinations; kidney and liver function tests were normal,lactate dehydrogenase:372 U/L,uric acid: 5.4 mg/dl,white blood cell:25000 × 106/L,lymphocyte: 15780 × 106/L, neutrophil:1140 × 106/L,hemoglobin:10 gr/dl, thrombocyte:12000 × 106/L,coagulation tests were normal and in peripheral blood smear evaluation,90% blast cells were detected. Peripheral blood flow cytometry evaluation was compatible with B-ALL(TdT,CD19,CD10,CD34,cCD79a,CD58,CD9,CD38,CD123,CD20,CD81,CD22 positivity in atypical cells).Bone marrow biopsy was hypercellular.There was diffuse blastic cell infiltration,which stained extensively with TDT,CD79a.Chromosomal analysis is 47XY,+21 and t(12,21) (p13.2;q22.12) (ETV6/RUNX1) (FISH) and 14q32.33 (IGH) FISH were positive,t(9;22) P190 -p210,t(4;11), t(1;19),11q23 were negative.The risk classification was standard risk. AUGMENTED BFM induction chemotherapy protocol was started.Pancreatitis was developed after peg-asparaginase and chemotherapy-related hepatotoxicity(grade 1) was developed.Central nervous system prophylaxis(intrathecal methotrexate) was applied.The control bone marrow biopsy performed after induction was normocellular,the blast rate was <5%.BFM standard risk first consolidation chemotherapy protocol was started.He died of septic shock on the eighteenth day of the first consolidation treatment. Cases of DS-ALL cases are at greater risk for serious side effects from chemotherapeutics,mortality and recurrence than non DS-ALL.Because children with DS have a higher incidence of treatment-related toxicity,survival rates are lower than non-DS children.During ALL induction chemotherapy life-threatening side effects are tumor lysis syndrome,thrombosis,bleeding and infection.In the UKALL 2003 study,DS associated with a significantly increased risk of death from sepsis during chemotherapy.

Hantavirus Disease and COVID-19.

Navajo Nation is disproportionately affected by hantavirus cardiopulmonary syndrome (HCPS), a severe respiratory disease that can quickly progress to respiratory failure and cardiogenic shock. The initial signs and symptoms of HCPS are indistinguishable from coronavirus disease 2019 (COVID-19). However, this distinction is critical, as the disease course differs greatly, with most patients with COVID-19 experiencing mild to moderate illness. We set out to determine if the evaluation of peripheral blood smears for five hematopathologic criteria previously identified as hallmarks of hantavirus infection, or "the hantavirus 5-point screen," could distinguish between COVID-19 and HCPS. The hantavirus 5-point screen was performed on peripheral blood smears from 139 patients positive for COVID-19 seeking treatment from Tséhootsooí Medical Center and two Emory University hospitals. Of these 139 individuals, 136 (98%) received a score of 3/5 or below, indicating low suspicion for HCPS. While thrombocytopenia, one of the key signs of HCPS, was seen in the patients with COVID-19, it was generally mild and remained stable on repeat specimens collected 12 to 24 hours later. Given these findings, the 5-point screen remains a useful rapid screening tool for potential HCPS cases and may be useful to distinguish early HCPS from COVID-19 in HCPS endemic regions.

Hairy Cell Leukemia (Morphologic and Immunophenotypic Profile)

Hairy Cell Leukemia (HCL) is a lymphoproliferative B cell abnormality dominated by mature lymphocytes with cytoplasmic projections and often misunderstood as Chronic Lymphocytic Leukemia (CLL). Misdiagnosis can be caused by errors in the preparation of peripheral Blood Smear Evaluation (BSE). Immunophenotyping is an option to differentiate HCL from CLL. A 56-year-old female presented with complaints of weakness. Physical examination showed conjunctival anemia 3 3 and hepatosplenomegaly. Hematological test results were as follows: Hb 7.4 g/dL; WBC 131.24x10 /uL; and Plt 61x10 /uL. BSE And Bone Marrow Aspiration (BMA) showed predominantly mature lymphocytes with cytoplasmic projections and suspected CLL with HCL as the differential diagnosis. Immunophenotyping with peripheral blood samples showed CD19+, CD20+, CD79a+, HLA-DR+, CD5-, and CD7- suggesting an increasing mature lymphocytes population (74.16%) that expressed B lymphoid lineage. White Precursor Cell (WPC) channel test showed an abnormal lymphocytes population. The differential diagnosis of patients with dominant mature lymphocytes BSE with cytoplasmic projections was CLL and HCL. Immunophenotyping of CLL showed positive results on B cell markers (CD19, CD20, CD79a, and HLA-DR) with aberrant CD5. However, in such an HCL case like this, there were strongly positive results on B cell markers but the absence of aberrant CD5. This study was supported by the presence of abnormal lymphocytes population in the WPC test. The diagnosis of HCL in this patient was based on interpretation of BSE and immunophenotyping, supported by the WPC test.

Reliability of Different RBC Indices and Formulas in the Discrimination of ?-Thalassemia Minor and Iron Deficiency Anemia in Surabaya, Indonesia

In this study, we evaluated the RBC indices in differentiating ?-thalassemia minor and iron deficiencyanemia in a healthcare center. This was an observational analytic study with a cross-sectional design usingblood specimens of children aged 3 years to 17 years with microcytic hypochromic anemia based onthe results of complete blood counts and evaluation of peripheral blood smears. Calculation of the RBCindices was performed as an initial screening to differentiate ?-thalassemia minor and iron deficiencyanemia. Iron profile examination and hemoglobin electrophoresis were performed to confirm the diagnosisof ?-thalassemia minor and iron deficiency anemia. The results of the independent samples t-test showedsignificant differences in Hb, MCV, MCH, and MCHC between ?-thalassemia minor and iron deficiencyanemia (p <0.05). The results of the Mann Whitney test showed a significant difference in the MentzerIndex to distinguish between ?-thalassemia minor and iron deficiency anemia (p <0.05). Also, the resultsof the independent samples t-test showed significant differences in the Green & King formula, Sirdah etal. formula, and the Maltos and Carvalho Index (p <0.05). The Green and King formula has a diagnosticsensitivity of 78.6% and a specificity of 76.6% and an accuracy of 78.03%. Various formulas based on theresults of complete blood count parameters have been developed to detect ?-thalassemia minor in areas witha high prevalence of ?-thalassemia with different sensitivity and specificity. In this study, it showed that theGreen and King formula has a diagnostic sensitivity of 78.6% and a specificity of 76.6%, and an accuracyof 78.03%. Green and King’s formula can be applied as an initial screening to differentiate ?-thalassemiaminor and iron deficiency anemia

Storage artefacts in peripheral blood smears

Introduction: Microscopic evaluation of peripheral blood smear is a very important investigation. Blood for various laboratory analyses are commonly kept in ethylene diamine tetra acetic acid (EDTA). EDTA can however cause morphological and fragility changes in blood cells. However, morphological analyses can be greatly hampered due to occurrence of artefacts. Aims and Objectives: To identify the storage artefacts and thus avoid misinterpretation of peripheral blood smears. Materials and Methods: 50 blood samples were obtained using EDTA and 3.5% sodium citrate as anticoagulants. Smears were made immediately as well as after 2, 4 and 6hrs of storage at room temperature. Smears obtained from same patients by finger prick method served as controls. Conclusion: EDTA has been recommended as the anticoagulant of choice for peripheral smear but should be examined within 1hr of collection to avoid misinterpretation as pathological findings leading to wrong diagnosis. Keywords: Peripheral smears, Anticoagulant, Platelets, Neutrophils, Artifacts.

Chronic Thrombocytopenia in Children: What Could It Hide?

Immune thrombocytopenic purpura (ITP) is one of the most common hemorrhagic disorders in childhood, often caused by an acute self-limiting event. However, 30% of these children develop chronic ITP. Identification of the underlying causes in ITP is an important challenge. Inherited thrombocytopenia (IT) is a rare, underdiagnosed disease, included among the chronic platelet disorders. Next-Generation-Sequencing (NGS) could be an efficient way of discovering potential IT-associated mutations in children with chronic ITP. The purpose of this retrospective study was to investigate children with chronic ITP using a targeted NGS, in order to identify IT-associated mutations. Between June 2017 and April 2020, mutational screening by a targeted NGS was performed on 19 children, either with a familial history of IT [4 unrelated patients (pts)], or with chronic ITP (15 pts), after all other causes of thrombocytopenia were excluded. Nineteen relatives were also investigated. This study was carried out in collaboration with the Laboratory of Genetics, IRCCS Burlo Garofolo in Trieste, that developed a targeted NGS method for the simultaneous analysis of 28 IT genes. The cost of the NGS tests were supported by the public healthcare service. We retrospectively divided our cohort of 19 pts, into three subgroups: Group I included 4 unrelated pts with familial IT; Group II consisted of 6 pts with chronic ITP and a clinical history and/or laboratory features associated with familial IT; and, Group III included 9 pts with chronic ITP refractory to several treatments (Table 1). The median age at the initial diagnosis of thrombocytopenia was lower in Group I than in Groups II and III (19/12 years vs 1310/12 years and 9 years, respectively, p=0.33). The median time between the diagnosis of thrombocytopenia, and the time of the study, was shorter in Group I compared to Groups II and III (11.7 months vs 45.3 and 51.7 months, respectively, p=0.16). Median platelet count at the disease onset was lower in Group III than in Groups I and II (21 x 109/L vs 99 x 109/L and 38 x 109/L, respectively, p=0.28). The median MPV values were 12.5 fL, 9.85 fL and 8.8 fL in Groups II, III, and I respectively. Bleeding symptoms requiring treatment were present at diagnosis in 1/6 (16%) and in 5/9 (55%) children of Groups II and III, respectively. Genetic variants, usually detected in IT, were found in heterozygosity in all children in Groups I and II, and in 7/9 (78%) in Group III. Two out of 4, 2/6 and 2/9 children in Groups I, II, and III, respectively, presented ≥2 variants. Among the 4 children of Group I, ANKDR26 variant was found in 2 pts, together with GP1BA and NBEAL2 (pt#1) and TUBB1 (pt#2). ANKDR26 variant was also recorded as a single mutation in their relatives. Two different variants involving GP1BA (c.98T&amp;gt;A and c.515C&amp;lt;T) were detected in the remaining 2 children of Group I and in their relatives. Pt #4 with GP1BA c.515C&amp;gt;T mutation with mild macrothrombocytopenia had relatives with a previous diagnosis of monoallelic Bernard-Souliers syndrome. As shown in table 1, ABCG8, ACTN1, ETV6, GP1BA, MYH9, SLFN14, or WAS variants, found in combination in 2 pts (pt#5, pt#8), were also detected in the children in Group II, as well as, at least one of the relatives (for a total of 7 cases). ABCG5, ABCG8, ETV6, FLNA, GP1BA, NBEAL2, or SLFN14 were found as variants in patients of Group III. The peripheral blood smear evaluation confirmed the diagnosis of grey platelet syndrome with two NBEAL2 mutations in pt #16. SLFN14, as a single variant, was associated with macrothrombocytopenia in one pt (#10). Three pts (#5, #6, #17), with variants of ABCG8 had hypercholesterolemia. In the cohort of pts with chronic ITP, 4 (#12, #13, #14, #15) had relatives with thrombocytopenia, and 2 (#11, #13) had a familial history of hematological malignancies. Segregation analysis in families, and functional studies to evaluate the pathogenic role of the variants reported, are still in progress. The clinical significance of IT-associated mutations in chronic ITP is uncertain, and yet to be clarified. However, our experience has shown that an in-depth clinical history, and accurate peripheral blood smear examinations, are important to better characterize chronic ITP in children. A targeted NGS method for the simultaneous analysis of different IT genes, has demonstrated to be an effective approach to explore in-depth the IT-associated mutations in children with chronic ITP, refractory to treatment. Table 1. Disclosures Giona: Novartis: Research Funding; Takeda: Speakers Bureau; Sanofi Genzyme: Research Funding, Speakers Bureau.

Analysis of changes in the morphology of erythrocytes – microscopic evaluation of peripheral blood smears

Analysis of changes in the morphology of erythrocytes – microscopic evaluation of peripheral blood smears

Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a crosssectional study in a tertiary care hospital.

Çağlar İ, Topal S, Çokboz M, Düzgöl M, Kara A, Bayram SN, Apa H, Devrim İ. Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a cross-sectional study in a tertiary care hospital. Turk J Pediatr 2019; 61: 368-373. Epstein-Barr virus (EBV) is widespread all over the world. It causes infectious mononucleosis (IM) mostly in adolescents and adults. Although IM is considered to be rare in younger children and infants, acute EBV infection may have various manifestations in this age group. We aimed to describe the clinical features and laboratory findings of children hospitalized with acute EBV infection. All children hospitalized at Dr. Behçet Uz Children`s Hospital, between January 2010 and January 2017, who tested positive by presence of EBV-specific antibodies and had the diagnosis of acute EBV infection, were included (n=66). Thirty four of the patients (51.5%) were under 6 years of age, and 23 (34.8%) children were below 3 years of age. The most common physical finding was fever (92.4%) followed by cervical lymphadenopathy and tonsillopharyngitis. Leukocytosis (65.1%) and lymphocytosis (42.4%) were the most common laboratory findings. Reactive and atypical lymphocytes were present in 77.2% of the patients. Fifty-three (80.3%) of the patients had a doctor visit before hospitalization, and the ratio of patients using antibiotics was 77.3%. Skin rash was observed in 14 (27.4%) of the patients who used antibiotic treatment and in 2 (13.3%) of the patients who did not (p > 0.05). EBV infection resulting in admission to hospital is common in younger children, even in pre-school period. Serological tests for EBV specific antibody responses and peripheral blood smear evaluation are important diagnostic tools. In addition, rapid streptococcal antigen test and throat culture should be performed in patients presenting with tonsillopharyngitis in order to exclude Group A beta-hemolytic streptococci and reduce unnecessary antibiotic consumption.

Can the leukocyte`s parameters in peripheral blood smear predict risk of in-hospital death of patients undergoing high-risk gastrointestinal surgery?

White blood cell (WBC) count constitutes a part of routine peripheral blood examination (FBC, full blood count). Precise analysis of leukocytes' parameters in blood smear is usually performed only when leukopenia or leukocytosis is found. We aimed to assess the usefulness of leukocytes' smear test in predicting in-hospital death of patients undergoing high-risk gastrointestinal (GI) surgery. Materials &amp; Methods. We prospectively enrolled 101 subjects undergoing high-risk GI surgery from 01.01.2017 till 31.12.2017. Blood tests were performed preoperatively, with analysis focused on the assessment of total WBC count, as well as the count of neutrophils (NEUT), lymphocytes (LYM), monocytes (MONO), eosinophils (EOS) and basophils (BASO). Indices of NEUT/LYM (NLR) and MONO/LYM (MLR) were calculated. In-hospital mortality was considered the outcome. Mortality reached 5%. There was no significant difference in WBC count between survivors and the deceased (p=0.2) and WBC failed to predict the outcome (AUC=0.69; p=0.3). MONO (p=0.009) and BASO (p=0.02) counts, as well as MLR (p=0.007) were significantly higher in patients who died. MONO count and MLR index predicted in-hospital death with good accuracy, respectively: AUC[MONO]=0.85 (p&lt;0.001) and AUC[MLR]=0.86 (p&lt;0.001). Other investigated parameters played no significant role in outcome prediction. Routine peripheral blood smear evaluation should be considered in all patients undergoing high-risk GI surgery, because the number of monocytes can be a valuable predictor of in-hospital death.

Live remote digital microscopy in peripheral blood smear evaluation: Intraobserver concordance and experience.

Peripheral blood smear (PBS) review is a routine laboratory test which requires pathologist's interpretation when abnormal indices, atypical cells, or critical findings are identified. Real-time remote digital microscopy (DM) can potentially facilitate rapid review when an on-site pathologist is not available. Herein, we assess intraobserver concordance of PBS evaluation with light microscopy (LM) and DM using VisionTek M6 robotic DM and TeamViewer imaging software. Thirty-seven de-identified PBS slides were evaluated by five reviewers. Slides were loaded on a VisionTek M6 robotic microscope at an off-site laboratory and evaluated remotely via TeamViewer software. Reviewers recorded interpretation, time required for interpretation (in minutes), imaging quality (score 0-3), and confidence of interpretation (score 0-3). Other relevant information associated with DM evaluation was also documented. Slides were subsequently evaluated using LM after washout interval. The intraobserver variation of results for impression, digital slide quality, minutes to interpretation, and confidence of interpretation was compared between DM and LM. The intraobserver concordance between LM and DM was 93%, with nine discordant interpretations among 135 evaluations under each review modality, respectively. Although reviewers spent more time under DM mode (5min/slide) than LM mode (2.5min/slide), the reviewers felt the DM provided sufficient image quality and the confidence levels of reviewers on slide interpretation were comparable between DM (2.6/3) and LM (2.8/3). There was a high level of intraobserver concordance and comparable interpretation confidence between DM and LM. DM can be a useful methodology for off-site pathologist's review of PBS.

TALASEMIA BETA HEMOGLOBIN E (Hemoglobin E Beta Thalassemia)

Thalassemia is a quantitative abnormality of the hemoglobin marked by inadequate hemoglobin synthesis due to the lack orabsence of synthesis of one or more globin polypeptide chains. Hemoglobin variant is a qualitative abnormality due to the presence ofthe abnormal amino acid sequence of one or more globin polypeptide chains. HbE β thalassemia is a disorder of hemoglobin that resultsfrom the fusion between the gene β-thalassemia allele from one parent with a gene HbE allele from another parent. In this case, HbEβ-Thalassemia patient was a 4.8 year girl diagnosed with hemoglobin E-beta thalassemia based on history and clinical manifestations;pale, the presence of splenomegaly and hepatomegaly. Laboratory tests were Hb: 7.7 g/dL, MCV: 52.9 fl, MCH: 17.7 pg, MCHC: 33.5g/dL and ferritin: 1012 ng/mL. Peripheral blood smear evaluation showed a microcytic hypochromic anemia with hemolytic signs andinfected features of leukocytes. Hb electrophoresis using HPLC showed a Hb F: 37.7% and HbA2 52.4%, indicating that HbA2 was falsehigh due to coeluating with HbE. The patient was treated by blood transfusion and received additional therapy such as folic acid, ironchelation and vitamin E.

Myelodysplastic Syndrome, Unclassifiable (MDS-U) With 1% Blasts Is a Distinct Subgroup of MDS-U With a Poor Prognosis.

Three situations qualify as myelodysplastic syndrome, unclassifiable (MDS-U): (1) refractory cytopenia with dysplasia and 1% blasts in peripheral blood (BL), (2) pancytopenia with unilineage dysplasia (Pan), and (3) persistent cytopenia, less than 5% bone marrow blasts, and less than 10% dysplastic cells and presence of MDS-defining cytogenetic abnormalities (CG). We compared the clinicopathologic features and mutational profiles for these three groups. MDS-U cases were reviewed at four major academic institutions. Targeted next-generation sequencing for genes implicated in myeloid neoplasms was performed in a subset of cases. Twenty-seven patients were identified (six MDS-U BL, 13 MDS-U Pan, and eight MDS-U CG). Clonal cytogenetic abnormalities were found in six of six, seven of 13, and eight of eight cases in MDS-U BL, Pan, and CG, respectively (P > .05). Overall, four of six patients with MDS-U BL progressed to acute myeloid leukemia; no MDS-U Pan or CG patients did. The rates of progression-free survival and mortality (overall survival) were significantly higher in MDS-U BL compared with Pan and CG (P < .001 for both). We find that MDS-U BL is a distinct subset of MDS-U with a poor prognosis, while MDS-U Pan and CG are relatively indolent. Evaluation of peripheral blood smears in patients with MDS is essential for accurate classification and prognosis.

Malaria rapid diagnostic test and Giemsa – stained peripheral blood smear discrepancies in the diagnosis of Plasmodium ovale infection in New England

Malaria is a serious mosquito-borne parasitic disease and is one of the most significant causes of death worldwide. In this report we discuss a case of a 26-year-old female healthcare worker who presented to the emergency department with signs and symptoms of persistent fevers, chills, headaches, nausea, and malaise. The patient9s history was obtained and several laboratory tests were performed leading to the diagnosis of malaria caused by Plasmodium ovale. The rapid diagnostic test for malaria was negative, and the Giemsa – stained peripheral blood smears were positive for the presence of malarial parasites. Images of the peripheral blood smears were sent to the Centers for Disease Control and Prevention, which confirmed the presence of Plasmodium ovale. We also report 5 other false negative RDTs for P. ovale in our institution in 2016, and the performance of RDTs for all malaria cases during that year. This case demonstrates the importance of obtaining multiple pieces of laboratory data in order to accurately diagnose a patient with malaria, illustrates that evaluation of Giemsa – stained peripheral blood smears is still the gold standard in the laboratory diagnosis of malaria, and emphasizes the importance for clinical laboratory scientists to maintain maximum competency in peripheral blood smear evaluation for bloodborne parasites. ABBREVIATIONS:CBC - Complete blood count, RDT - Rapid Diagnostic Test, RBCs - Red blood cells, CDC - Centers for Disease Control and Prevention, AST - Aspartate Aminotransferase, ALT - Alanine Aminotransferase

Abnormal Scenes in a Blood Film

Examination of peripheral blood smear is a vital step in assessment of overall health status of the individual. Blood smear examination is part of standard hematologic profiles and as a part of the diagnostic evaluation of apparently ill patient. In addition to differential leucocyte count, blood smear examination may reveal a variety of information of diagnostic value, for instance defective RBC morphology suggests chronic blood loss, endogenous or exogenous intoxication, vascular disorders or immune mediated disorders. Pathomorphological changes in WBCs are the first signs of inflammatory conditions and may be diagnostic for certain inherited conditions and leukemias that can be only are detected through microscopic evaluation of peripheral blood smears. In some cases, infectious agents pathognomonic cellular inclusions, and neoplastic cells are observed on blood films, yielding an immediate, definitive diagnosis. Every complete blood count (CBC) should be followed by blood smear evaluation that provides morphologic confirmation of hematologic parameters, assurance of the quality of values obtained from automated analyzers, and additional important information not given by automated methods. It is very easy and inexpensive to prepare a blood smear and one can acquire experience readily in evaluation of blood smear with regular practice supported by adequate background information.

TALASEMIA BETA HEMOGLOBIN E

Thalassemia is a quantitative abnormality of the hemoglobin marked by inadequate hemoglobin synthesis due to the lack or absence of synthesis of one or more globin polypeptide chains. Hemoglobin variant is a qualitative abnormality due to the presence of the abnormal amino acid sequence of one or more globin polypeptide chains. HbE β thalassemia is a disorder of hemoglobin that results from the fusion between the gene β-thalassemia allele from one parent with a gene HbE allele from another parent. In this case, HbE β-Thalassemia patient was a 4.8 year girl diagnosed with hemoglobin E-beta thalassemia based on history and clinical manifestations; pale, the presence of splenomegaly and hepatomegaly. Laboratory tests were Hb: 7.7 g/dL, MCV: 52.9 fl, MCH: 17.7 pg, MCHC: 33.5 g/dL and ferritin: 1012 ng/mL. Peripheral blood smear evaluation showed a microcytic hypochromic anemia with hemolytic signs andinfected features of leukocytes. Hb electrophoresis using HPLC showed a Hb F: 37.7% and HbA2 52.4%, indicating that HbA2 was false high due to coeluating with HbE. The patient was treated by blood transfusion and received additional therapy such as folic acid, iron chelation and vitamin E

Significance of teardrop cells in peripheral blood smears

Abstract Teardrop erythrocytes (syn. dakryocytes) play a key role in the evaluation of peripheral blood smears in patients with anemia, especially as part of the “leukoerythroblastic picture”. Teardrop-shaped red blood cells can be seen in a wide range of diseases that lead to bone marrow fibrosis, which is often accompanied by extramedullary hematopoesis. The differential diagnoses encompass primary myelofibrosis (PMF), myelodysplastisc syndromes during the late course of the disease, rare forms of acute leucemias and myelophtisis caused by metastatic carcinoma. Rarely, MF associated with post-irradiation, toxins, autoimmune diseases, metabolic conditions, inborn hemolytic anemias, iron-deficient anemia or β-thalassaemia can lead to the formation of teardrops as visualized on peripheral blood smears.

Chanarin-Dorfman Syndrome with Multi-System Involvement in Two Siblings

Chanarin-Dorfman syndrome (CDS) is a very rare autosomal recessive inherited neutral lipid metabolism disorder associated with congenital ichthyosis and multi-system involvement. Observation of lipid vacuoles in neutrophils (Jordan’s anomaly) in peripheral blood smears in patients with ichthyosiform erythroderma is diagnostic. Herein we present 2 siblings with CDS that were referred to Dokuz Eylul University School of Medicine Department of Pediatrics due to ichthyosis. They had hepatomegaly, cataract, growth retardation, and sensorineural hearing loss. Some lipid vacuoles in neutrophils were noted in peripheral blood smear evaluation. Genetic analysis showed homozygous N209X mutation in both patients. They were put on a low-fat high-carbohydrate diet supplemented with medium-chain fatty acids. During 6 months of follow-up, no improvement was observed in both patients. In conclusion, although CDS is a rare lipid storage disease, it should always be a consideration in patients with congenital ichthyosis, especially those with extracutaneous symptoms or signs. The diagnosis of CDS is made based on a very simple test-peripheral blood smear.Conflict of interest:None declared.

Evaluation of an Automated Digital Imaging System, Nextslide Digital Review Network, for Examination of Peripheral Blood Smears

Several automated digital imaging systems have been introduced in recent years to improve turnaround time and proficiency in examining peripheral blood smears in hematology laboratories. To evaluate a new automated digital imaging system, Nextslide Digital Review Network (Nextslide), for examination of peripheral blood smears. We evaluated 479 peripheral blood smears, of which 247 (51.6%) were included for comparison of Nextslide and manual white blood cell differential counts and morphology evaluation, 204 (42.6%) were included for comparison of Nextslide and CellaVision (DM96) differential counts, and 28 (5.8%) were neonatal samples examined for enumeration of nucleated red blood cells. Results from both method comparisons showed excellent correlation for all major white blood cell classes with correlation coefficients ranging from 0.70 to 0.99. Evaluation of white blood cell, red blood cell, and platelet morphology also showed good correlation among methods. White blood cell preclassification capability in the system was evaluated for rate and accuracy. Leukopenic samples demonstrated markedly decreased review time with Nextslide. Enumeration of nucleated red blood cells showed good correlation among methods. Our evaluation of Nextslide shows excellent correlation when compared with conventional manual differentials and CellaVision (DM96) differentials for evaluation of peripheral blood smears.

Evaluation of Peripheral Blood Smear for Myelodysplasia in Breast Cancer Patients who Received Adjuvant Antracycline.

Therapy-related myeloid neoplasms (t-MN) account for approximately 10% to 20% of all cases of AML (acute myeloid leukemia), MDS (myelodysplastic syndrome) and MDS/MPN (myelodysplastic syndrome/myeloproliferative neoplasms), MDS, and MDS/MPN. In our study, we evaluated peripheral blood smear samples and hemogram values in breast cancer patients who were receiving adjuvant anthracycline regimens and were in remission. A total of 78 patients receiving anthracycline-based adjuvant chemotherapy treatment from Kayseri Research and Training Hospital and Mersin State Hospital were enrolled in the study. Their adjuvant treatments had been completed at least 18 months prior to the study. Two patients complained of anemia (2.2%) (Hb<11 mg/dl), leukopenia was observed in seven patients (7.7%) (leukocytes<4000/ mm(3)), and thrombocytopenia was observed in four patients (4.4%) (PLT<150.000/mm(3)). In the blood smear samples, the following were observed: ovalomacrocytes (14%), macrocytes (37%), acanthocytes (1%), stomatocytes (12%), teardrops (12%), nucleated erythrocytes (1%), basophilic stippling (14%), and Howell-Jolly bodies (1%). Additionally, hypo-granulation (38%), Pelger-Huet abnormalities (26%), hypersegmentation (20%), immature granulocytes (8%), and blasts (6%) were observed. We also confirmed the presence of giant platelets (50%) and platelet hypogranulation (19%). According to the peripheral blood smear assessments in our study, we suggest that breast cancer patients should be evaluated for MDS in the early stages, starting from month 18, even if the automated blood counts are normal.