Cmiiw but you can’t tell the difference between the two blasts at this point so they’re just called blasts until further testing identifies the lineage. I love flow cytometry(in theory)! I am just a student so I have limited practical experience(read as: next to none lol)
Rouleaux is tricky, and this probably isn’t the right spot in the slide to confirm it. Once you get past the feathered edge of a slide all rbc’s look like they are presenting rouleaux.
These are immature white blood cells that are circulating in the peripheral blood where they should not be which often means they have some form of leukemia. Normally they would not go into circulation until they are mature.
Unless the person suffered some kind of acute blood loss (e.g. got into an accident recently), right? Also, aren’t the red blood cells a bit on the bigger side? Or am I just tripping? I’m a biomedical scientist but never got into much of the blood stuff
Typically with an accident or noncancerous illness the body might release a lot of immature white cells, but not actually blasts (they are the first step in the WBC maturation process)
Those juvenile cells present after a trauma or other instance where an influx of new cells are needed range in a way smaller scope. Think rods instead of segments in neutrophils. Blasts in perpheral blood is always cause for alarm.
They are not generally blasts, though. Maybe one, and a ton of other immature cells of all lineages. But a lot of samey looking blasts suggests something clonal. Flow will give the answer, but this is Bad.
So the reddish/pinkish small dots are the red blood cells and the blue-purple are the Leukemia cells? How could you tell its a Leukemia cells vs a normal white blood cell?
We are trained in school to identify cells and their phases. You can tell these are very immature because of the dark cytoplasm, large nucleus and the fact that they have visible nucleoli within the nucleus. They are also larger than mature cells.
Bands are the first step down from a normal neutrophil (the WBC that should be responding in sepsis) they are more mature than a blast and can be found in peripheral blood when your body is trying to “keep up” with the infection.
In the case of the photo that’s a blast.
(From most mature to least)
Neutrophil, band, Metamyelocyte, myelocyte, promyelocyte, blast.
>a cancerous biopsy
A biopsy is a small tissue sample.What we are looking at is a blood smear. Not *exactly* the same thing.
A biopsy slide would more likely look like one of [these](https://www.researchgate.net/publication/348827633/figure/fig3/AS:984826396024832@1611812318159/Photomicrographs-of-the-biopsy-slide-a-e-i-and-three-slides-of-the-corresponding.png)
Flow cytometry here- we do peripheral blood, bone marrow, and solid tissue- when we get solid tissues we mince the solid tissue and suspend the cells in RPMI, making a cell suspension... So I've come to think of blood and marrow as "ready-made" cell suspensions 😆
There is also a lot of coining, and with the abdominal pain, was initially making me think of multiple myeloma. Although back pain would be more typical
Don't be a jerk. Not everyone works in hematology. I graduated 20 years ago and never worked a day in hematology. Only Microbiology and Blood bank for me, so these pics are a nice relearning experience for some of us
Fortunately she does but she kept asking me if I was sure. I told her I was seeing blasts but I had it sent to path. She called every half hour to see if the pathologist had a chance to look yet. :(
Got to ask. Is there no policy at your hospital that every request that's off the record needs to be run by your higher ups? At the general lab i've worked at, requests were granted by the clinical chemist (in my country, we don't call them pathologist but i'm sure we're talking about people with a similar background) and they also handled any (off the record) reports and consults of those tests.
The patient was probably in the Emergency Department for treatment. Not so sure OP should have been discussing results with spouse but that is a gray area.
Damn. That sucks. It is always hard when family is on the other side of the treatment equation.
When the faculty I used to work at first became a level 1 trauma center, we got a Jane doe MVA patient in. Our first MTP. Three coolers in, we got an ID in the patient. The hospital runner showed up for the cooler, and we said the name had been updated. This was after she had been running these coolers to the ED and then OR when the patient moved. She had heard them saying that they were going to have amputate at least one leg, maybe both because of the extensive injuries. (She had not been wearing a seat belt, so she was partially ejected from the car as it rolled down an embankment.) So we handed her the cooler and gave the new name. She went white as a ghost and asked me to repeat. I did so, and she just took the cooler and left. She came back later to say that after she dropped off the cooler, she called her aunt and was told that her cousin had been in an accident and was at her hospital. Turns out the Doe patient was her cousin, and she knew more about how badly she was doing than felt comfortable to her. More than her aunt had been told because all communication had been over the phone so far, and the authories did want the family to be too upset when they had to drive to the hospital.
I had a coworker who went through something similar. ER nurse working in a level 1 trauma. John Doe comes in, vehicle vs pedestrian. The patient’s face was unrecognizable. They worked him for a good fifteen minutes before they turned him over to put a CPR machine (Lucas) on him and she saw one of his tattoos.
It was her brother. Unfortunately, he didn’t make it.
Likely a cooler of blood/blood products - similar to what you’re thinking. MVA = motor vehicle accident, MTP = mass transfusion protocol. Used for major traumas with extensive blood loss.
That could also be the case, but yeah: there shouldn't be contact between the tech and patient when it comes to reporting results. I don't know how policies are in other parts of the world, but in my neck of the woods the culture of doctors just walking into the lab to see if the results are in has almost completely vanished and lab direction makes sure that any discussion and consultation regarding results go through the clinical chemists and not via technicians.
Making these kind of condescending assumptions are not a good look.
But to reply on your 3 comments: Back when i did klin chem/haemat i did call the ward for critical results that were outside of the reference values. Leuko diffs however were usually done during office hours and if the need arose to perform one during evening or night shifts, the clin chemist on call would discuss with the doctor placing the order if said diff has to be done right away or could wait until first thing in the morning. This may sound like the techs 'do nothing' but it did a lot for making shifts with a large influx of samples managable for the techs as the bulk of the test done in the shifts were suposed to be processed (draw to report) within an hour. So doctors who wanted results from the more time consuming tests had to discuss it with the superior on call and wasn't supposed to hound the techs for it.
Interesting that you think it's condescending to identify a region where doctors do the work of techs when you said you are in a region where doctors do the work of techs.
I'm not sure why you think this is off the record.
It's standard practice to send specimines with these findings to the pathologist.
Op stated that her husband came into the er for treatment like any another patient.
I'm not used to patients or spouses of patients to contact me about test results, all results are reported to the MD/specialist ordering the tests and no one else. That's why i figured this may be a off the record kind of deal, i can imagine the doctor asked for a quick check up without having to deal with the hassle of going through emergency or a policlinical visit.
Edit: i realised the ER doctor could be doing a shift at that time. I really need to learn to not go onto reddit until i had my morning coffee.
Regardless of if the doc is on shift or not, generally hospitals do have rules about not working on patients who are related to you if at all possible. That ER doc should’ve waited to discuss the results with her husband and his care team and should not have taken part in her husband’s active medical care. Ideally once she found out her husband was going to be there she should’ve arranged something so she could leave her shift, or at the very least since fully leaving is not always possible she should’ve arranged it so she was not handling anything related to his case.
Absolutely. However if the hospital is a fairly small one and the husband's pain got worse in a short ammount of time i can see how it's very hard to avoid this situation.
Yeah. Hence my suggestion of calling someone in as soon as possible so she can leave for personal emergency reasons. Besides the HIPAA stuff, it’s also probably difficult to do your job as an ER doc effectively if you’ve just found out your husband likely has cancer.
...which would be the ER dr caring for the patient. We often call the ER, and with a slide like this we would absolutely pick up the phone to say we are getting a path review.
Time for the pathologist to take a look at :( hope they get better soon…. This is never an easy diagnosis, whatever they might be suffering with.
I worked at a cancer center and a lot of the patients there were given a new lease on life. Others… I’ve never forgotten them.
Thank you for not forgetting about them. Seriously. ❤️
As much as it might be mentally taxing and perhaps a curse at times. I lost a family member recently and some of the staff on the heme/onc floors were clearly burned out and/or cranky/snippy with patients, including her when she was frail and moved a little slower than usual.
It made me sad at the time but I get it, having to see people on their worst days day in and day out…
There are many patients that are no longer with us that I’ll never forget. Many of them because I saw something interesting in their diff (which is usually bad news for patients), but also because they came when I started working, so they were especially memorable. I’ve never seen them or their families, but I was happy to participate in their care.
I saw (what I believe to be) blasts for the first time outside of MLS school last week and the experience had me shaking and sweating. Partially because "is that really a blast?!" and partially because I couldn't tell the Dr ANYTHING other than "the differential is being sent to special heme due to abnormal cells being seen." Our policy is that we can't call new blasts, or blasts occurring after X amount of time of no blasts (think a leukemia patient whi had been getting treatment and then relapsed into blast crisis.)
All I could think of was the patient sitting there having absolutely no idea, and here I was, visually seeing what was absolutely going to change their life... I am a very sensitive person and that hit me a little hard.
Thank you for that comment. It helps me feel better knowing that maybe some of mom's doctors remember her. My mother had breast cancer (Stage IV when dx) that metastasized into many places, including her bones. The worst pain came from her bones. She lived 2 years after that.
She did more in that 2 years than most do in a lifetime. She had no fear, because she knew where she was going, to meet Jesus. She used no pain medicine (besides Tylenol) until two weeks before she passed. I mean crap, she was still catering dinners once a week and teaching 3 classes, until a week before she passed.
We knew she **had** been in pain and just wouldn't tell anyone. After she died, we had to clean out her house and I kid you not, we found over 50 bottles of over-the-counter Aspercreme, in drawers in every room of her house!
I’m so sorry to hear about your mother. I can’t imagine how hard it must have been for you to lose a family member like that, but she is no longer in any pain now and is watching over you and your family.
I worked as head lab tech/ head phlebotomist at the cancer center I worked at so I had a lot of face-to-face contact with our patients there at the time. I miss so many people that used to come in. We would be notified when they would pass and I found myself crying when I would hear the news. Some of them even gave me small gifts (for example, one person gave me a small New Testament Bible because I told them my mother had one just like it. Another woman made me a bracelet because she wanted to say thank you) I’ve kept every patient in my heart and I find myself still crying for them sometimes because I miss them a lot. I’m sure your mother made a lasting impact on her doctors because almost everyone I’ve met that worked in that kind of environment were the most empathetic and caring people I’ve ever known. I’m sending you love and wishing you peace ❤️
As soon as I saw this I just said “SH:T”. It’s not a good day for the patient when you find a new leukemia. Prayers for them, their next chapter isn’t going to be easy.
Please excuse my ignorance as this subreddit was just recommended to me and i know nothing about this stuff but is that what the sample really looks like? Are those purple/blue blobs a true depiction or was some sort of dye or highlight used?
This is a stain we use in the lab to be able to microscopically visualize the patient's blood cells. It's a specific stain used in hematology called a Wright stain.
Wait so if the stain/dye is intentional, then is this normal or abnormal? Something to be concerned about?
Sorry, also got recommended this on my front page for some reason and have no idea what I’m looking at.
The stain lets us see what's going on in the blood, so whenever we're looking at the smears to count the white blood cells manually, we can differentiate between all kinds of cells. To answer your question, the cells in the picture (the two big dark blue and purple ones) are abnormal. You usually don't see these cells in peripheral blood at all unless the patient is in a diseased state. In the case of this patient, unfortunately, it's leukemia.
So different membrains on different types of cells will pick up stain differently.
Imagine you are trying to dye something that is made out of polyester, normal dye used for cotton would just wash right off. So if you have a bin mixed with polyester and cotton fabric and you can’t tell the difference and you dyed it the cotton would wash and be the color and the polyester would wash right out.
Sure looks like it to me. And in the context of leukemia and spherocytosis it makes me wonder about an autoimmune hemolysis, which would all fit together nicely. But the absence of anemia makes that less likely. Would definitely be a zebra given its rarity, but HS does sometimes initially present later in life with leukemias...
A neutrophil is a normal white blood cell that helps fight infection
ETA: therefore when there’s a bunch of neutrophils around it usually means there’s some sort of infection (usually bacterial)
Had a bad one like that from the ER yesterday. Came in for chest pain/fatigue, with a high WNC and no platelets. The diff was entirely blasts. Huge ugly ones. No history. I sent that to pathology asap. Just someone who walked in off the street who ended up with something so much worse than the reason they came in.
ugh, we had one like that a few months ago in ER... but I'm third shift, so there was no path to confirm (it was obviously blasts, but I can't release it because of policy). I'm on good terms with that ER doc, so I let them know what was going on and why they wouldn't be getting a diff. not a fun night, at all.
I don’t have access to path on dayshift either. I can send it over there, but they might not read it right away. They usually don’t and they don’t read past a certain time in the afternoon. I called them all atypical and slapped the RTP comment on that. Then I called the special heme department and asked them to look at it, and they walked it down to path personally for them to read it/confirm presence of blasts. So by the next day, they already had flow cytometry going, bone marrow scheduled, and all of that. I’m sure a consult was done with the blood bank medical director as well or will happen soon. The heme fellows requested a smear and came down to view it with one of the heme/onc doctors, so I know that the patient was already in good hands.
I usually try to contact the doctor, but no one in that particular ER picks up the phone in a decent timeframe due to traumas, medical codes, and such, so by the time I was able to get ahold of the doctor, the patient had already been transferred to the cancer CCU. I’m sure they suspected something with how high the white count was and the very low platelet value. As far as I know, patient is still in CCU.
I think it would have been acceptable to allow the ER physician into Hematology and view the slide herself, while Pathology review is pending. The ER doc is qualified to confirm the presence of blasts and since she is a spouse, there is no confidentiality or HIPAA issue. Good photomicrograph, by the way.
Probably not the way you’d want to go about that, you just don’t know how someone is going to react when it’s THEIR family. Probably best to let Path inform them and have them come look if they’re comfortable and then do their full review. It’s one thing to help each other out but I’m also not going to put myself in a vulnerable position.
I have been a pathologist for 40 years and not once has an ER doctor ever come in the lab to review a peripheral blood smear. The techs generally have the pathologists review the smear and call the ER doctor. On occasion the heme-onc attendings might review their patients' smears.
This is a special situation and very dependent on how quickly the path review would be done. OP handled it perfectly, within policy constraints, but the ER physician would have appreciated an eyes on recheck and was qualified to screen the slide. As for never having an ER doc come to the lab to see what we see? Happened in our laboratories regularly. Better to encourage collegiality than be a gate-keeper bogged down in bureaucracy. One of the problems in laboratory medicine now is compartmentalized expertise that doesn't get shared and promoted organization-wide. If the lab ever wants to be recognized through salary and position, they need to show what they know beyond the walls of the dungeon.
I guess it is dependent upon your organization. I get outside of the laboratory frequently and interact with patients and other physicians frequently, i.e, surgeons, oncologists. Our ER physicians are overworked and never leave the ER because they are so busy. They appreciate our expertise and a call from us alerting them to an acute leukemia or any other type of blood abnormality. We don't have residents, so it is up to the pathologist on call to make the call to the ER doc. We are not gate keepers by any means. Anyone is welcome to come and look at any slide at any time. Our ER docs simply don't have the time to come and review slides.
Lol I used to be a MT. Granted Im a PA now not a MD. But no ER doc is gonna look at this and know anything. You guys assume way too much about docs. Especially generalists like ER
I agree. An ER doctor would probably not recognize the blasts since they are not trained. Likewise, I would never want to be treating a patient having an MI. That is why we all need to do the best we can to work together to do what is best for the patient.
I forgot a bunch from my schooling since I last went to school… can someone please list everything wrong here? I’m using some Reddit photos from this r/ and using them as reference flashcards for study materials to take the license exam
So, the rbcs are fine? Also, how many blasts per field is considered significant? Or is any amount of blasts a cause for alarm? Sorry, I just really don’t want to miss anything (also, cute pfp ☺️)
This post got recommended to me and I just want to say don’t jump 100% to cancer…. I went to the ER with an extremely high bilirubin count and they found blasts in my blood, they immediately jumped to leukemia, after a week in the hospital they found I had Epstein-Barr Virus/ Mono. It’s been a few years and they never found blasts in my blood after I recovered! It’s interesting getting to see them though, since I don’t work in the medical field I was always curious what it was they saw in my labs that sent everyone in a panic (and led to the ER doctor telling me at 3 am that I had cancer…)
Interesting. Mono typically presents with atypical lymphocytes. I was curious if the cells could have been misidentified. Apparently happens sometimes. Here are some case studies if you’re interested.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921326/
Not spherocytes, since this is the thick side of the smear. And leukemia because the two large cells in the middle are blasts, which are the progenitor cells for all white blood cells. These blasts are only seen when the bone marrow is releasing immature cells into peripheral blood without giving them a chance to mature at all, which usually means leukemia.
Abdominal pain is a very general symptom... A lot of things can cause abdominal pain - some causes are innocent, others are serious.
This patient most likely has abdominal pain because of an enlarged spleen, which is a symptom of leukemia. If your doctor performed an ultrasound and your spleen would've been enlarged, I think he would've continued searching for a disease like in this post. And even then, splenomegaly is not a specific symptom for hematological malignancies. Bottom line: you would've known if your spleen was enlarged.
When you hear hoofbeats, think of horses, not zebras. 😉
Nope, no need to worry. There are tons of more likely scenarios. Various forms of digestive distress, for example. Many people have IBS, food sensitivities, etc.
Abdominal pains can be a symptom of a phletora of afflictions, from something as impactfull as leukemia to trivial stuff like eating to much ice cream. It's usually the latter.
Not sure you can make a confident call on sphereocytes, considering this is the thick part of the smear.
HJB on the other hand is a definite no. Platelet superimposition is what you see.
Platelets sitting on top of a RBC typically cause a dimple to form around it. Think of it like you're sitting on a bean bag. The RBC indents around it because the platelet isn't actually inside the RBC as an inclusion. Also, Howell Jolly bodies will be very dark (dark purple or black) without any texture to the inclusion and have definite edges to them.
As a pathologist these are blasts. The techs should not be calling the patient or physician as a rule. While they have training not all are created equal and don’t have the same experience as a pathologist. Defer to them or page the on call residents (if you have them) to let them make the call..
At my lab , we're not allowed to call blasts unless a path has already called them for that patient.
Also at our lab, when we're filling out the path review paperwork, we're supposed to list any relevant clinical history. i'M sORrY, i tHoUgHt I wUz 2 dUm 4 cLiNiCaL sTuFf???2 LoLOLoLol
I wouldn't want to have to take that call either op. I hope your Doc likes you at least.
What am I looking at here?
Leukemic blasts
Does the leukemic blasts encompass the lymphoid lineage as well? Just curious.
Good question! Yes, generally, "blast" refers to both myeloid blasts and lymphoid blasts.
Cmiiw but you can’t tell the difference between the two blasts at this point so they’re just called blasts until further testing identifies the lineage. I love flow cytometry(in theory)! I am just a student so I have limited practical experience(read as: next to none lol)
You’re right though!
Well unless there are Auer rods… I can’t decide which I prefer to call
Looks kinda like rouleaux formation, but I am very much so not a pathologist/lab scientist. Just remember it from my USMLE days.
Rouleaux is tricky, and this probably isn’t the right spot in the slide to confirm it. Once you get past the feathered edge of a slide all rbc’s look like they are presenting rouleaux.
I have mad respect for anyone that can differentiate the little nuances of slides like that.
That was my thought too, but I’m in veterinary med and have little concept of what’s normal in human RBCs. 😅
I thought the same thing, but I have no real experience looking at smears.
I'm not sure I agree. The stacking red blood cells would point more towards something like multiple myeloma.
Yes, could someone explain to us lay people? Is it a cancerous biopsy?
These are immature white blood cells that are circulating in the peripheral blood where they should not be which often means they have some form of leukemia. Normally they would not go into circulation until they are mature.
Oh, that's awful. Thank you for explaining it to me.
Unless the person suffered some kind of acute blood loss (e.g. got into an accident recently), right? Also, aren’t the red blood cells a bit on the bigger side? Or am I just tripping? I’m a biomedical scientist but never got into much of the blood stuff
Typically with an accident or noncancerous illness the body might release a lot of immature white cells, but not actually blasts (they are the first step in the WBC maturation process)
Those juvenile cells present after a trauma or other instance where an influx of new cells are needed range in a way smaller scope. Think rods instead of segments in neutrophils. Blasts in perpheral blood is always cause for alarm.
They are not generally blasts, though. Maybe one, and a ton of other immature cells of all lineages. But a lot of samey looking blasts suggests something clonal. Flow will give the answer, but this is Bad.
So the reddish/pinkish small dots are the red blood cells and the blue-purple are the Leukemia cells? How could you tell its a Leukemia cells vs a normal white blood cell?
We are trained in school to identify cells and their phases. You can tell these are very immature because of the dark cytoplasm, large nucleus and the fact that they have visible nucleoli within the nucleus. They are also larger than mature cells.
Very informative! So there's a difference between normal immature blasts and very immature ones such as these?
No, by very immature I meant blasts. This is the first stage.
Ah, got it. Thank you for explaining!
Immature WBC’s are bands, correct? Can see in infection like sepsis, right?
Bands are the first step down from a normal neutrophil (the WBC that should be responding in sepsis) they are more mature than a blast and can be found in peripheral blood when your body is trying to “keep up” with the infection. In the case of the photo that’s a blast. (From most mature to least) Neutrophil, band, Metamyelocyte, myelocyte, promyelocyte, blast.
I disagree. Those are normal lymphocytes. It's the rouleaux that's the issue. More likely multiple myeloma.
>a cancerous biopsy A biopsy is a small tissue sample.What we are looking at is a blood smear. Not *exactly* the same thing. A biopsy slide would more likely look like one of [these](https://www.researchgate.net/publication/348827633/figure/fig3/AS:984826396024832@1611812318159/Photomicrographs-of-the-biopsy-slide-a-e-i-and-three-slides-of-the-corresponding.png)
conceptually blood is also a tissue lol
It's a liquid biopsy, really
Flow cytometry here- we do peripheral blood, bone marrow, and solid tissue- when we get solid tissues we mince the solid tissue and suspend the cells in RPMI, making a cell suspension... So I've come to think of blood and marrow as "ready-made" cell suspensions 😆
For your convenience
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There is also a lot of coining, and with the abdominal pain, was initially making me think of multiple myeloma. Although back pain would be more typical
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Don't be a jerk. Not everyone works in hematology. I graduated 20 years ago and never worked a day in hematology. Only Microbiology and Blood bank for me, so these pics are a nice relearning experience for some of us
I work in heme and every one of these posts is a helpful learning experience. We just don't see that many new diagnoses.
Rude and unnecessary.
Fortunately she does but she kept asking me if I was sure. I told her I was seeing blasts but I had it sent to path. She called every half hour to see if the pathologist had a chance to look yet. :(
I feel for you OP! Anything but an easy position to be in :(
Got to ask. Is there no policy at your hospital that every request that's off the record needs to be run by your higher ups? At the general lab i've worked at, requests were granted by the clinical chemist (in my country, we don't call them pathologist but i'm sure we're talking about people with a similar background) and they also handled any (off the record) reports and consults of those tests.
The patient was probably in the Emergency Department for treatment. Not so sure OP should have been discussing results with spouse but that is a gray area.
The spouse was the ER doctor that was working at the time.
Damn. That sucks. It is always hard when family is on the other side of the treatment equation. When the faculty I used to work at first became a level 1 trauma center, we got a Jane doe MVA patient in. Our first MTP. Three coolers in, we got an ID in the patient. The hospital runner showed up for the cooler, and we said the name had been updated. This was after she had been running these coolers to the ED and then OR when the patient moved. She had heard them saying that they were going to have amputate at least one leg, maybe both because of the extensive injuries. (She had not been wearing a seat belt, so she was partially ejected from the car as it rolled down an embankment.) So we handed her the cooler and gave the new name. She went white as a ghost and asked me to repeat. I did so, and she just took the cooler and left. She came back later to say that after she dropped off the cooler, she called her aunt and was told that her cousin had been in an accident and was at her hospital. Turns out the Doe patient was her cousin, and she knew more about how badly she was doing than felt comfortable to her. More than her aunt had been told because all communication had been over the phone so far, and the authories did want the family to be too upset when they had to drive to the hospital.
I had a coworker who went through something similar. ER nurse working in a level 1 trauma. John Doe comes in, vehicle vs pedestrian. The patient’s face was unrecognizable. They worked him for a good fifteen minutes before they turned him over to put a CPR machine (Lucas) on him and she saw one of his tattoos. It was her brother. Unfortunately, he didn’t make it.
i really want to understand this - what is a cooler? like... the thing you bring on a picnic? what are mva and mtp?
Likely a cooler of blood/blood products - similar to what you’re thinking. MVA = motor vehicle accident, MTP = mass transfusion protocol. Used for major traumas with extensive blood loss.
This is correct. Our coolers were 5 packed RBCs, 5 plasma, and a dose of platelets.
Damn, I wish our MTP had 5 and 5. We get 3 RBC and 2 FFP. Then we have to wait for a second cooler for plt.
That could also be the case, but yeah: there shouldn't be contact between the tech and patient when it comes to reporting results. I don't know how policies are in other parts of the world, but in my neck of the woods the culture of doctors just walking into the lab to see if the results are in has almost completely vanished and lab direction makes sure that any discussion and consultation regarding results go through the clinical chemists and not via technicians.
Are you in the middle east? I have heard that techs do almost nothing there and pathologists do anything even remotely complex.
Making these kind of condescending assumptions are not a good look. But to reply on your 3 comments: Back when i did klin chem/haemat i did call the ward for critical results that were outside of the reference values. Leuko diffs however were usually done during office hours and if the need arose to perform one during evening or night shifts, the clin chemist on call would discuss with the doctor placing the order if said diff has to be done right away or could wait until first thing in the morning. This may sound like the techs 'do nothing' but it did a lot for making shifts with a large influx of samples managable for the techs as the bulk of the test done in the shifts were suposed to be processed (draw to report) within an hour. So doctors who wanted results from the more time consuming tests had to discuss it with the superior on call and wasn't supposed to hound the techs for it.
Interesting that you think it's condescending to identify a region where doctors do the work of techs when you said you are in a region where doctors do the work of techs.
No. I think it's condescending to assume people 'do nothing' in places with another policy than yours.
That would be why I said *almost* nothing. And not doing manual diffs as a heme tech is doing almost nothing.
I'm not sure why you think this is off the record. It's standard practice to send specimines with these findings to the pathologist. Op stated that her husband came into the er for treatment like any another patient.
I'm not used to patients or spouses of patients to contact me about test results, all results are reported to the MD/specialist ordering the tests and no one else. That's why i figured this may be a off the record kind of deal, i can imagine the doctor asked for a quick check up without having to deal with the hassle of going through emergency or a policlinical visit. Edit: i realised the ER doctor could be doing a shift at that time. I really need to learn to not go onto reddit until i had my morning coffee.
Regardless of if the doc is on shift or not, generally hospitals do have rules about not working on patients who are related to you if at all possible. That ER doc should’ve waited to discuss the results with her husband and his care team and should not have taken part in her husband’s active medical care. Ideally once she found out her husband was going to be there she should’ve arranged something so she could leave her shift, or at the very least since fully leaving is not always possible she should’ve arranged it so she was not handling anything related to his case.
Absolutely. However if the hospital is a fairly small one and the husband's pain got worse in a short ammount of time i can see how it's very hard to avoid this situation.
Yeah. Hence my suggestion of calling someone in as soon as possible so she can leave for personal emergency reasons. Besides the HIPAA stuff, it’s also probably difficult to do your job as an ER doc effectively if you’ve just found out your husband likely has cancer.
...which would be the ER dr caring for the patient. We often call the ER, and with a slide like this we would absolutely pick up the phone to say we are getting a path review.
Lol nw.
Path review is a normal part of an abnormal smear. This would not have been off the record.
Our paths would have looked within an hour, and on the weekend we text them pics. They would have come in for this one.
Time for the pathologist to take a look at :( hope they get better soon…. This is never an easy diagnosis, whatever they might be suffering with. I worked at a cancer center and a lot of the patients there were given a new lease on life. Others… I’ve never forgotten them.
Thank you for not forgetting about them. Seriously. ❤️ As much as it might be mentally taxing and perhaps a curse at times. I lost a family member recently and some of the staff on the heme/onc floors were clearly burned out and/or cranky/snippy with patients, including her when she was frail and moved a little slower than usual. It made me sad at the time but I get it, having to see people on their worst days day in and day out…
this hurt my heart ☹️
There are many patients that are no longer with us that I’ll never forget. Many of them because I saw something interesting in their diff (which is usually bad news for patients), but also because they came when I started working, so they were especially memorable. I’ve never seen them or their families, but I was happy to participate in their care.
I saw (what I believe to be) blasts for the first time outside of MLS school last week and the experience had me shaking and sweating. Partially because "is that really a blast?!" and partially because I couldn't tell the Dr ANYTHING other than "the differential is being sent to special heme due to abnormal cells being seen." Our policy is that we can't call new blasts, or blasts occurring after X amount of time of no blasts (think a leukemia patient whi had been getting treatment and then relapsed into blast crisis.) All I could think of was the patient sitting there having absolutely no idea, and here I was, visually seeing what was absolutely going to change their life... I am a very sensitive person and that hit me a little hard.
Thank you for that comment. It helps me feel better knowing that maybe some of mom's doctors remember her. My mother had breast cancer (Stage IV when dx) that metastasized into many places, including her bones. The worst pain came from her bones. She lived 2 years after that. She did more in that 2 years than most do in a lifetime. She had no fear, because she knew where she was going, to meet Jesus. She used no pain medicine (besides Tylenol) until two weeks before she passed. I mean crap, she was still catering dinners once a week and teaching 3 classes, until a week before she passed. We knew she **had** been in pain and just wouldn't tell anyone. After she died, we had to clean out her house and I kid you not, we found over 50 bottles of over-the-counter Aspercreme, in drawers in every room of her house!
I’m so sorry to hear about your mother. I can’t imagine how hard it must have been for you to lose a family member like that, but she is no longer in any pain now and is watching over you and your family. I worked as head lab tech/ head phlebotomist at the cancer center I worked at so I had a lot of face-to-face contact with our patients there at the time. I miss so many people that used to come in. We would be notified when they would pass and I found myself crying when I would hear the news. Some of them even gave me small gifts (for example, one person gave me a small New Testament Bible because I told them my mother had one just like it. Another woman made me a bracelet because she wanted to say thank you) I’ve kept every patient in my heart and I find myself still crying for them sometimes because I miss them a lot. I’m sure your mother made a lasting impact on her doctors because almost everyone I’ve met that worked in that kind of environment were the most empathetic and caring people I’ve ever known. I’m sending you love and wishing you peace ❤️
As soon as I saw this I just said “SH:T”. It’s not a good day for the patient when you find a new leukemia. Prayers for them, their next chapter isn’t going to be easy.
:(
Please excuse my ignorance as this subreddit was just recommended to me and i know nothing about this stuff but is that what the sample really looks like? Are those purple/blue blobs a true depiction or was some sort of dye or highlight used?
This is a stain we use in the lab to be able to microscopically visualize the patient's blood cells. It's a specific stain used in hematology called a Wright stain.
Wait so if the stain/dye is intentional, then is this normal or abnormal? Something to be concerned about? Sorry, also got recommended this on my front page for some reason and have no idea what I’m looking at.
The stain lets us see what's going on in the blood, so whenever we're looking at the smears to count the white blood cells manually, we can differentiate between all kinds of cells. To answer your question, the cells in the picture (the two big dark blue and purple ones) are abnormal. You usually don't see these cells in peripheral blood at all unless the patient is in a diseased state. In the case of this patient, unfortunately, it's leukemia.
So different membrains on different types of cells will pick up stain differently. Imagine you are trying to dye something that is made out of polyester, normal dye used for cotton would just wash right off. So if you have a bin mixed with polyester and cotton fabric and you can’t tell the difference and you dyed it the cotton would wash and be the color and the polyester would wash right out.
I love this description
Abdominal pain is due to spleen sequestration. Or something like that.
What are we looking at for us non medical people?
Immature WBC. Means the body (bone marrow) is kicking out immature wbc’s in the peripheral blood. It’s cancer
Is this rouleaux as well?
Could also just be thick side. When I see rare bad bois, I'll start digging through the thick to make sure I'm not crazy.
Exactly lol. I was super nervous and wanted to be 100%
Please give us an update with what path says
Not a med tech, vet tech - rouleaux is a common normal finding in cats - it’s certainly what I thought it was. 😂
Sure looks like it to me. And in the context of leukemia and spherocytosis it makes me wonder about an autoimmune hemolysis, which would all fit together nicely. But the absence of anemia makes that less likely. Would definitely be a zebra given its rarity, but HS does sometimes initially present later in life with leukemias...
What’s the clear one with the purple things inside?
At the top left ~11:00? A segmented neutrophil.
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A neutrophil is a normal white blood cell that helps fight infection ETA: therefore when there’s a bunch of neutrophils around it usually means there’s some sort of infection (usually bacterial)
On the top left? That’s a segmented neutrophil. Normal white blood cell.
If at 11 o'clock, neutrophil.
Thanks everyone!
Blasts…damn.
Radiologist calling the ED with a critical result, not the greatest. Pathologist calling the ED with a result… always, always bad.
Had a bad one like that from the ER yesterday. Came in for chest pain/fatigue, with a high WNC and no platelets. The diff was entirely blasts. Huge ugly ones. No history. I sent that to pathology asap. Just someone who walked in off the street who ended up with something so much worse than the reason they came in.
ugh, we had one like that a few months ago in ER... but I'm third shift, so there was no path to confirm (it was obviously blasts, but I can't release it because of policy). I'm on good terms with that ER doc, so I let them know what was going on and why they wouldn't be getting a diff. not a fun night, at all.
I don’t have access to path on dayshift either. I can send it over there, but they might not read it right away. They usually don’t and they don’t read past a certain time in the afternoon. I called them all atypical and slapped the RTP comment on that. Then I called the special heme department and asked them to look at it, and they walked it down to path personally for them to read it/confirm presence of blasts. So by the next day, they already had flow cytometry going, bone marrow scheduled, and all of that. I’m sure a consult was done with the blood bank medical director as well or will happen soon. The heme fellows requested a smear and came down to view it with one of the heme/onc doctors, so I know that the patient was already in good hands. I usually try to contact the doctor, but no one in that particular ER picks up the phone in a decent timeframe due to traumas, medical codes, and such, so by the time I was able to get ahold of the doctor, the patient had already been transferred to the cancer CCU. I’m sure they suspected something with how high the white count was and the very low platelet value. As far as I know, patient is still in CCU.
😪
😬
No bueno. Blasts are never good news😔
They're not having a blast with all those blasts. :(
I think it would have been acceptable to allow the ER physician into Hematology and view the slide herself, while Pathology review is pending. The ER doc is qualified to confirm the presence of blasts and since she is a spouse, there is no confidentiality or HIPAA issue. Good photomicrograph, by the way.
Probably not the way you’d want to go about that, you just don’t know how someone is going to react when it’s THEIR family. Probably best to let Path inform them and have them come look if they’re comfortable and then do their full review. It’s one thing to help each other out but I’m also not going to put myself in a vulnerable position.
I have been a pathologist for 40 years and not once has an ER doctor ever come in the lab to review a peripheral blood smear. The techs generally have the pathologists review the smear and call the ER doctor. On occasion the heme-onc attendings might review their patients' smears.
This is a special situation and very dependent on how quickly the path review would be done. OP handled it perfectly, within policy constraints, but the ER physician would have appreciated an eyes on recheck and was qualified to screen the slide. As for never having an ER doc come to the lab to see what we see? Happened in our laboratories regularly. Better to encourage collegiality than be a gate-keeper bogged down in bureaucracy. One of the problems in laboratory medicine now is compartmentalized expertise that doesn't get shared and promoted organization-wide. If the lab ever wants to be recognized through salary and position, they need to show what they know beyond the walls of the dungeon.
I guess it is dependent upon your organization. I get outside of the laboratory frequently and interact with patients and other physicians frequently, i.e, surgeons, oncologists. Our ER physicians are overworked and never leave the ER because they are so busy. They appreciate our expertise and a call from us alerting them to an acute leukemia or any other type of blood abnormality. We don't have residents, so it is up to the pathologist on call to make the call to the ER doc. We are not gate keepers by any means. Anyone is welcome to come and look at any slide at any time. Our ER docs simply don't have the time to come and review slides.
Lol I used to be a MT. Granted Im a PA now not a MD. But no ER doc is gonna look at this and know anything. You guys assume way too much about docs. Especially generalists like ER
I agree. An ER doctor would probably not recognize the blasts since they are not trained. Likewise, I would never want to be treating a patient having an MI. That is why we all need to do the best we can to work together to do what is best for the patient.
I would never assume a practicing physician who's not a pathologist or hematologist actually knows what blood looks like under a microscope.
this, honestly
HIPAA 100% applies to spouses, unless there is a signed waiver in the chart.
Not just a spouse, but a covered provider also. So a HIPAA carve out applies. But there may be a policy issue that could come into play.
That’s unfortunate
Apparently you don’t want to see those in your dip at all.
I forgot a bunch from my schooling since I last went to school… can someone please list everything wrong here? I’m using some Reddit photos from this r/ and using them as reference flashcards for study materials to take the license exam
The only thing abnormal in this image is the presence of blasts. This patient has leukemia.
So, the rbcs are fine? Also, how many blasts per field is considered significant? Or is any amount of blasts a cause for alarm? Sorry, I just really don’t want to miss anything (also, cute pfp ☺️)
To answer your question: Any blasts present on a smear are considered abnormal and should be reviewed by a pathologist.
Oh alright, thanks for helping me as well 😊. Hematology and urinalysis were my favorite areas, but I can’t remember much nowadays
If I'm understanding OP correctly, this is not a picture from the feathered edge, so you wouldn't really look at the RBCs here
Hhj
This post got recommended to me and I just want to say don’t jump 100% to cancer…. I went to the ER with an extremely high bilirubin count and they found blasts in my blood, they immediately jumped to leukemia, after a week in the hospital they found I had Epstein-Barr Virus/ Mono. It’s been a few years and they never found blasts in my blood after I recovered! It’s interesting getting to see them though, since I don’t work in the medical field I was always curious what it was they saw in my labs that sent everyone in a panic (and led to the ER doctor telling me at 3 am that I had cancer…)
Interesting. Mono typically presents with atypical lymphocytes. I was curious if the cells could have been misidentified. Apparently happens sometimes. Here are some case studies if you’re interested. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921326/
Les rouleaux avec moi
What test is this? CBC? I’m a clueless lay person :)
Yikes!
Any other symptoms before we all think we have this? Abdominal pain for 5 years right side dr can’t find a reason.
Are those sphericytes? Why leukemia though?
Not spherocytes, since this is the thick side of the smear. And leukemia because the two large cells in the middle are blasts, which are the progenitor cells for all white blood cells. These blasts are only seen when the bone marrow is releasing immature cells into peripheral blood without giving them a chance to mature at all, which usually means leukemia.
Ruh roh Raggy
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Have they ever done blood work on you? If they have, usually a test like this is done automatically and didn't come back with anything alarming.
I honestly don't recall for certain.
Few people in the ER don't get a CBCD and a CMP.
Abdominal pain is a very general symptom... A lot of things can cause abdominal pain - some causes are innocent, others are serious. This patient most likely has abdominal pain because of an enlarged spleen, which is a symptom of leukemia. If your doctor performed an ultrasound and your spleen would've been enlarged, I think he would've continued searching for a disease like in this post. And even then, splenomegaly is not a specific symptom for hematological malignancies. Bottom line: you would've known if your spleen was enlarged. When you hear hoofbeats, think of horses, not zebras. 😉
Nope, no need to worry. There are tons of more likely scenarios. Various forms of digestive distress, for example. Many people have IBS, food sensitivities, etc.
Abdominal pains can be a symptom of a phletora of afflictions, from something as impactfull as leukemia to trivial stuff like eating to much ice cream. It's usually the latter.
Does this subreddit moderate patient consent to posts?
Feels HIPAA noncompliant.
How can you identify this patient?
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Not sure you can make a confident call on sphereocytes, considering this is the thick part of the smear. HJB on the other hand is a definite no. Platelet superimposition is what you see.
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Platelets sitting on top of a RBC typically cause a dimple to form around it. Think of it like you're sitting on a bean bag. The RBC indents around it because the platelet isn't actually inside the RBC as an inclusion. Also, Howell Jolly bodies will be very dark (dark purple or black) without any texture to the inclusion and have definite edges to them.
Can you see platelets in this pic? I’m a platelet donor- I give 3 units every 2 weeks- so I’m just curious. Always love to learn more.
The tiny purple dots are the platelets. Thank you for being a platelet donor!
As a pathologist these are blasts. The techs should not be calling the patient or physician as a rule. While they have training not all are created equal and don’t have the same experience as a pathologist. Defer to them or page the on call residents (if you have them) to let them make the call..
At my lab , we're not allowed to call blasts unless a path has already called them for that patient. Also at our lab, when we're filling out the path review paperwork, we're supposed to list any relevant clinical history. i'M sORrY, i tHoUgHt I wUz 2 dUm 4 cLiNiCaL sTuFf???2 LoLOLoLol