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MEDT 4600
Hematology Review
Instructions:
1. Please print this document (5 case studies). Read the cases carefully and answer the
questions.
2. CBC units are given in Case Study A and are the same throughout the cases.
3. These are real patient case studies and they are meant to be challenging!!! You will need
to use your notes, books and other resources for assistance in answering the questions.
4. To submit answer you will need to type them in using the assignment icon associated
with these case studies. You will be graded on this assignment and it is part of your 4600
grade. Short answers are preferable but you need to provide enough information for me
to fully understand your answer. You will not get an immediate score. I have to
manually grade this assignment. Be patient!
5. Submit the answers to the case study before due date. No extensions will be given. No
late answers accepted.
6. Answers will be posted after all cases have been submitted.
Case Study A
History: A 6-year-old male is admitted to the hospital for a work up for juvenile-on-set
diabetes mellitus. He was also being treated for a macrocytic anemia.
Lab results were:
WBC 2.9 (x10
9
/L)
RBC 2.53 (x10
12
/L)
HGB 10.2 (g/dL)
HCT 29.3 (%)
MCV 116.0 fL
MCH 40.6 (pg)
MCHC 34.2 (%)
RDW 18.1 (%)
PLT 76 (x10
9
/L)
Retic 0.4%
Question 1 – What is the most likely diagnosis based on the lab results above?
Additional testing:
Bone Marrow:
Decreased M:E ratio
3% Blasts
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Peripheral Blood Smear:
Macrocytic RBCs
Low platelet count
Hyposegmented neutrophils
Treatment
Patient was given vitamin B12 for 6 weeks– no change in the anemia status (patient did not
respond to treatment)
Question 2 – Does our patient have megaloblastic anemia? Why or why not?
Question 3 – Looking at ALL the lab results again, what is another possible diagnosis for this
patient?
Patient Outcome
Patient was given supportive therapy for 4 years (packed red blood cells and platelets). Patient
died of overwhelming infections
Case Study B
History: A 44-year-old male was first seen in the VA hospital and then transferred to the city’s
larger hospital for re-evaluation. He was not responding to treatment that was prescribed.
Lab results were:
WBC 122.2
RBC 2.48
HGB 8.2
HCT 26.0
MCV 90.7
MCH 32.9
MCHC 36.3
RDW 14.3
PLT 27
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Coagulation:
Fibrinogen 67 mg/dl
PT 19.3 sec
INR 2.0
PTT 39.5 sec
FSP >40 µg/dl
D-dimer 4250 NG/ML
Question 1 – What do the above lab results indicate?
Additional testing
Peripheral Blood Smear Day 1:
Several large WBCs with a large amount of nucleus, bi-lobed nucleus and hypogranular.
These cells were reported as monocytes (monocytosis)
Peripheral Blood Smear Day 2:
On this day the MT performing the differential called the abnormal WBCs hypogranular
promyelocytes.
Question 2 – Based on the additional testing from Day 1, what is the best possible diagnosis?
Yet the results were different on Day 2, what is the best possible diagnosis based on the
peripheral blood smear results from Day 2?
Patient Outcome
Patient died about 3 months later
Case Study C
History: A 4-year-old male presents to his local pediatrician with irritability, loss of appetite
and a distended abdomen. (Patient has a twin brother who is healthy and has not previous
history of illness.) On physical exam the patient was febrile and irritable. The spleen was
massively enlarged, liver was normal size and there was not lymphadenopathy.
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Lab results were:
WBC 298.9
RBC 3.38
HGB 11.0
HCT 33.0
MCV 85.6
MCH 30.6
MCHC 33.2
RDW 17.4
PLT 366
Retic 1.4%
LAP Score: 6
Philadelphia chromosome: Negative
Bone Marrow:
Hypercellular marrow
Peripheral Blood Smear:
All immature stages seen including bands, myelocytes, metamyelocytes,
promyelocytes, blasts. Absolute monocytosis was aboserved .
Kleihaur-Betke stain indicated that roughly 45% of RBCs contained HbF.
Question 1 – What is the best diagnosis based on all the lab results? (Be specific this is a
subgroup disease.)
Patient Outcome
Patient did not respond to treatment. Patient died and four months later his brother was
diagnosed with the same disease.
Case Study D
History: A retired seventy-year-old male while sailing around the world fell on his yacht.
When examined by a local hospital (in Brazil) a fractured hip and pneumonia were found. He
returned to the U.S. for a follow up.
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Lab results were:
WBC 5.7
RBC 2.83
HGB 9.0
HCT 27.0
MCV 95.5
MCH 31.9
MCHC 33.4
RDW 23.4
PLT 101
Peripheral Blood Smear:
28% plasma cells
Rouleaux was noted
Question 1 – What do the above lab results indicate?
Additional testing
Protein Electrophoresis:
Albumin 30.5%
Alpha 1 2.6%
Alpha 2 8.4%
Beta 5.9%
Gamma 53.6%
Question 2 – What results are abnormal in the protein electrophoresis testing?
Additional testing
Immunoglobulin Quantitation:
Result Reference
IgG 307 723-1,685 mg/dl
IgA 1069 69-382 mg/dl
IgM 31 63-277 mg/dl
Question 3 – What is the final diagnosis based on ALL of the lab results?
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Case Study E
History: A 53-year-old male developed flu like symptoms with a high fever that progressed
over the course of the week. Other symptoms include a weakness in his arms and legs, joint
pains, painful headache and a sensitive scalp.
Lab results were:
WBC 3.7
RBC 3.45
HGB 11.0
HCT 34.0
MCV 89.5
MCH 29.7
MCHC 33.2
RDW 14.1
PLT 118
Differential:
Segs 72%
Lymphs 9%
Mono 19%
Retic 2.0%
*MT noticed erythrocyte intracellular ring-like structures.
Chemistry:
AST 4863
ALT 1855
ALP 72
Total Bilirubin 0.6
Direct Bilirubin 0.3
Total protein 6.0
Additional Information: Several of the rings like structures were extracellular and the patient
has never been outside of the U.S.
Question 1 – Based on all of the results and information, what is the best possible diagnosis?
And how was the patient most likely infected with this disease?
