Os h1

OSCE PEDIATRICS
HEMATOLOGY SPOTS PART 1
www.dnbpediatrics.com

Anatomy of PS

Red Cells
• Circular
• Mean cell diameter of 8
um(7.2-7.9)
• Central pallor does not
exceed more than one
half the diameter of the
cell.
• Ideal part of PS– Red cells
are just beginning to
touch and overlap.

Platelets
• Granular basophilic forms
with a mean diameter of
1-2 um.
• Platelet adequacy:
- 8-15 platelets
(individually or in small
clumps) per 100x oil
immersion field or
- 1 platelet for every 10-30
RBCs.

Neutrophils
• Round cells (10-14um)
• 2-5 lobes connected by a
thin thread of chromatin
• Chromatin stains purple
• Cytoplasm is pink with
purple granules
• Barr body

Band or Stab forms
• Nucleus is U shaped
• Rudimentary lobes
connected by a thick
band rather than a
thread.

Eosinophil
• Same size as
neutrophils
• 2 lobes
• Nucleus lightly stained
• Orange red granules
all over the cell.

Basophil
• Slightly smaller than
neutrophils
• Has deeply basophilic
granules

Monocyte
• Largest cells in
peripheral blood
• Nucleus– round,
kidney-shaped,oval or
lobulated and folded.
• Cytoplasm is light blue
or grey with fine
purple granules

Lymphocyte
• Small-10 um in
diameter
• Large-20 um in
diameter
• Nucleus-large
rounded, densely
stained
• Cytoplasm-scanty,
pale to dark blue.

N0RMAL SMEAR

An 8 month old female child BONCM
brought with increasing pallor noticed
since the last 1 month.
• Diet h/o -- breast feeding with adequate
food
On examination,
• Wellgrown
• Pale and irritable
• L-1.5 cm,S-1.5 cm.

• 1) Describe peripheral smear
• 2) Diagnosis on PS
• 3) Give 4 causes of hypochromic microcytic
• anemia
• 4) give 2 PS changes which are not present
that would point it to be a smear of thal trait.

• 1) hypo,micro, aniso, poikilo, tear drop cell
• 2) hypo, micro anemia
• 3) iron def
• Thal
• Sideroblastic anemia
• Anemia of chronic disease
• HbH
• Atransferrinemia
• 4) basophilic stippling and target cells.

After treatment

• 1) Describe PS
• 2) Name 3 conditions in which dimorphic red
cell population is seen.

• 1)Micro,hypo,macro, aniso,poikilo, tear drop
cells, polychromasia
• 2) iron def responding to iron therapy
• After the transfusion of normal blood to a
patient with a hypochromic anemia
• 3) Sideroblastic anemia

• What would you do if the child with proved
iron def after receiving adequate iron therapy
comes back showing no response?

• Suspect poor compliance
• Iron salt being used may be ineffective
• Increased blood losses
• GI causes
• Worm infestations
• H.Pylori
• Giardiasis
• Absorption defect
• Coeliac disease
• IBD
• Autoimmune gastritis

 A 9 month male child has
• fever since 15 days on and off
• Pallor – 15 days
• No other significant history
 On examination,
• Liver--2 cm
• Spleen – 2.5cm
• Rest of the examination -- Normal

• 1) Describe the specific PS change which
points it to being a homozygous Thal smear.
• 2) Name 4 conditions with increased Hb F.
• 3) Give the genotype of 4 transfusion
independent thal intermedia conditions.

• 1) Nucleated red cells.
• 2) increased HbF
• HPFH
• δβ thalassemia
• Congenital red cell aplasia
• Congenital aplastic anemia(Blackfan-Diamond
and Fanconis anemia)
• JCML
• Some MDS

• Slight increase in erythropoeitic stress
• (hemolysis, bleeding, recovery from acute BM
failure, pregnancy).
• 3) Genotype
• Some β+/β+ thal homozygotes
• Interaction of β0/ β0, β0/ β+ or β+/β+ with α
thal.
• Interaction of β0/ β or β+/β with triple α

• HbH disease
• α 0 / Hb Constant Spring thal
• Β0/δβ or Β+/δβ thal compound heterozygotes
• δβ/ δβ thal
• Some cases of HbE/β thal and Hb Lepore/ β
thal
• Rare cases of heterozygotes for β thal
invol.exon 3 (dominant β thal)

A 10 yr old male child BONCM
- Fever-low grade since 1 month
- Easy fatiguability since 15-20 days
-Tingling numbness in lower limbs since
10 days
On examination-
- Pallor ++
- Haemic murmur
- Other systems--normal

• 1) Describe PS
• 2) Diagnosis on PS
• Which other PS changes should have been
present to support your diagnosis.
• 3) Name at least 2 other conditions with
neutrophilic hypersegmentation

• 1) macro,aniso,poikilo,hypersegmented
neutrophils
• 2)megaloblastic anaemia
• Oval macrocytes,Baso stippling, HJ bodies,cabt
rings
• 3) hypersegmented neutrophils--- Uraemia
• Iron def
• Cytotoxic Rx esp. methotrexate
• Hydroxycarbamide Rx

• 3) Define neutrophilic hypersegmentation
• 4) Give 6 other differentials of macrocytosis

• 3) presence of 1 or more 6 lobed neutrophils or of 5 or
more neutrophils with 5 or more well separated lobes
among 100 segmented neutrophils.
• 4) macrocytic anemia--- megaloblastic anemia
• Aplastic anemia
• Myelodysplastic syn.
• Hydroxycarbamide Rx
• Chronic liver disease
• CDA type III
• Benign familial macrocytosis
• Hypothyroidism
• Increased erythropoeisis.

• 2 weeks later,the child is clinically responding
but the neutrophilic hypersegmentation is still
persisting
• Would you worry and change your line of Mx

2
1
5
4
3

• Name the circled cells and name the
conditions in which they are seen

• 1) Pencil cells--- Iron def
• 2) stomatocytes ---- hereditary stomatocytosis
• Southeast Asian ovalocytosis
• Liver disease
• Alcoholism
• Myelodysplastic syndromes
• Artifact

• 3) Tear drop cell- Iron def anemia
• Congenital hemolytic anemias
• Microangiopathic hemolytic anemia
• Oxidant damage
• 4)Leptocyte---- iron def anemia
• Thal
• 5) Howell jolly body--- pernicious anemia
• After splenectomy,splenic atrophy
• Dyserythropoeitic anemia
• Severe iron def

 A 6 yr old male child presents with fever of 2 days
duration with acute abdominal pain since 1 day.
He has never been symptomatic in the past.
 On examination,
• Pallor ++
• Icterus ++
• L3cm,S6cm
• Other systems—normal.

CBC
- Hb—9.8gm% -WBC—10,500/cumm
- Hct—29.4% -P-55,L-45
- RBC—4 106 -Platelet—3.5 105
- MCV—85 fl
- MCH---27 pg -Retic--- 5.6%
- MCHC—34 %
- RDW– 14.6%

• 1) clinical diagnosis
• 2) Name 4 conditions with spherocytosis
• 3) Is Osmotic fragility test specific for
hereditary spherocytosis.

• 1) Spherocytosis--- HS
• ABO hemolytic disease
• Autoimmune hemolytic
anemia
• Cl. Welchi sepsis
• 2) NO

• 3) what is the mode of inheritance of HS
• 4) Name 2 specific test to diagnose Hereditary
spherocytosis.
• 5) Give 5 causes of false positive DAT test

• 3) AD
• 4) Cryohemolysis test
• Memb. Protein analysis by Sodium dodecyl
sulfate polyacrylamide gel electrophoresis
• 5) alloantibody as in hemolytic disease of
newborn or after an incompatible Tx
• Drugs--- Quinidine,penicillin,cephalosporin
• Sepsis
• After ATG or ALG administration

• Gp O platelets with high titre antiAor B to gp A
or B recipient.
• IvIg may contain ABO or antiD antibodies.
• As a result of antiphospholipid antibodies in
APLA syndrome and SLE.
• Sickle cell disease because of IgG coated red
cells.

• Sickling test on this patient is negative, explain
• Which test next will you perform
• Newborn screening ---- is it performed
routinely and how?
• If detected as sickle cell disease what steps
will you take next?

• False negative
• Low Hb
• Outdated reagents
• Infants younger than 6 months
• Post Tx in which HbS level is < 20%.
• False positive---
• Severe leucocytosis
• Hyperproteinaemias
• Unstable Hb esp. after splenectomy

• Newborn screening routinely performed in US and UK
• Dried blood spot samples--- High Performance Liquid
Chromatography or IsoElectricFocussing
• Umbilical cord blood samples---- Hb electrophoresis
using cellulose acetate or citrate agar or HPLC or IEF.
• Parents CBC and Hb electrophoresis
• Penicillin prophylaxis
• Repeat babys Hb electrophoresis at 6 months of age.

• A 2.6 yr old asymptomatic child went for
cough/cold. CBC showed microcytosis,put on
hematinic.
• On follow up, inspite of being treated
adequately as a case of iron def anemia
microcytosis persisted.
• Referred to the hematologist.

• 1) Name the cell
• 2) Why do they occur
• 3) 5 conditions in which target cells are seen

• 1) Target cell
• 2)Disproportionately large surface compared to
volume
• 3) Liver disease
• Hereditary hypobetalipoproteinemia
• Iron def
• Thal
• Hbpathies--- HB C/β 0 thal
• HbC disease

• Sickle cell anemia
• Sickle cell/HbC disease
• Sickle cell/ β thal
• Hb E disease
• Post splenectomy

• 1) Name the intracellular inclusion
• 2) Name the conditions in which it is seen.

• 1)Cabot ring
• 2) lead poisoning
• Pernicious anemia
• Hemolytic anemias

• 1) Name the cell
• 2) how will you investigate this patient

• 1) Basophilic stippling
• 2) Megaloblastic anemia
• lead poisoning
• Thalassemia
• Infections
• Liver disease
• Unstable hemoglbins
• Pyrimidine nucleotidase 5 def

• A 2 yr old child has diarrhoea with oliguria
with severe dehydration.The resident starts
treatment and sends the CBC which shows
low Hb with normal indices and low platelets.

• 1)Name the cell
• 2) Name 4 conditions in which these cells are
seen
• 3) Difference between acanthocyte and
echinocyte
•

• 1)Schistocytes and acanthocytes
• 2) In certain genetic disorders( thal, CDA,
hereditary pyropoikilocytosis)
• Megaloblastic or dyserythropoeitic disorders
• Microangiopathic hemolytic anemia/cardiac
hemolytic anemias
• Direct thermal injury

• 3) Acanthocyte--- small no. of spicules of
inconsistent length, thickness and shape,
irregularly disposed over the surface of the cell.
• Seen in abnormal phospholipid metabolism
• Inherited abnormalities of RBC memb protein as
in McLeod phenotype
• Postsplenectomy
• Hyposplenism
• Liver disease

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