Question

            A 43-year-old man is seen by his primary care physician. He complains of excessive tiredness and a lack of stamina in activities he typically performs (work, sports). He recently noticed excessive bleeding from his gums after brushing his teeth. On physical examination, his physician noted lymphadenopathy and multiple petechiae on his torso, arms and legs. A CBC with differential and a coagulation panel were ordered. The results are as follows:

CBC

WBC (x 10⁹/L)               25.0

            RBC (x 10¹²/L)               2.80

            HGB (g/dl)                    8.4

            HCT (%)                       24.1

            RBC INDICES

                        MCV (fl)            86.1

                        MCH (pg)          28.9

                        MCHC (g/dl)     34.9

            RDW (%)                      14.2

            PLT (x 10⁹/L)                 29

DIFFERENTIAL

            WBC identification                    Relative (%)                              Absolute (x 10⁹/L)         

                        segs                                    3                                                    0.8

                        lymphs                              11                                                    2.8                   

                        monos                                 2                                                    0.5                   

                        eos                                      0                                                    0                    

                        basos                                  0                                                    0

                        promyelocytes                   64                                                   16.0                   

                        blasts                                 20                                                   5.0                                                                                                                             

RBC morphology:       Normocytic, normochromic; few schistocytes noted.

            Platelet estimate            2/ OIF

COAGULATION PANEL

         PT = 16.4 seconds (reference range 11.0 -13.0 seconds)

         APTT = 42.0 seconds (reference range 21.0-35.0 seconds)

         TT = 15.2 seconds (reference range 7.0-12.0 seconds)

         FIBRINOGEN = 78 mg/dL (reference range 200-400 mg/dL)

QUESTIONS

1. Identify the abnormal results seen in the laboratory testing performed on this patient.

            A bone marrow aspirate and biopsy were performed. The BM was hypercellular with      few blasts; promyelocytes were the predominant cell and many contained bundles of            Auer rods. Megakaryocytes were absent. Cytochemical staining was completed on the       BM sample with the results as follows:

                        Myeloperoxidase                             positive

                        Sudan Black B                             positive

                        Chloroacetate esterase                   positive

                        Alpha-naphthyl butyrate esterase   negative

                        Periodic Acid Schiff                        negative

           

           

2. Does this patient’s test results suggest an acute or a chronic disorder? Justify your

                answer.

3. Explain why cytochemical staining was ordered on this patient.

            4. For EACH cytochemical stain listed above,

                        (a) state what specific cellular component (i.e. enzyme, glycogen, lipid) is

                            reacting with the stain

                        (b) identify which cell line(s) will react with the stain.(above)

            5. Cytogenetic analysis was also ordered on this patient. A translocation of the long

                 arms of chromosomes 15 and 17 was identified. Discuss the clinical use for cytogenetic analysis in hematology.

            6. Based on the physical exam results and all the laboratory data, what would the FAB

                and WHO classification (group and subgroup) be for this patient?

            7. Based on your answer to question #6:

                        What result would you predict for EACH of the following cell markers using

                        monoclonal antibodies?

                             CD10, CD13, CD33, CD34, CD11b, CD14, Glycophorin A, HLA-DR

            8. Explain the likely cause for the coagulation results seen on this patient.

           

9. What is the prognosis and likely therapeutic regimen for someone with this disorder?

                       

           

Answer 1

1. Here we can see there is an abnormality that is increased WBC count, less RBC, Hemoglobin, and platelet and fibrinogen count and as well as there is an increased PT, APTT, and TT levels.

2. The bone marrow of the patient shows that there is hypercellular with few blasts and contains Auer rods shows it as an acute disorder.

3. To confirm the type of leukemia cytochemical staining is ordered to the patient

4. Myeloperoxidase, Chloroacetate esterase, and  Alpha-naphthyl butyrate esterase are enzymes

Sudan Black B are lipids/non-enzymatic and  Periodic Acid Schiff and glycogen or non-enzymatic

Here the SBB and MPO positive indicates that the reaction product is black and granular and nuclei are blue.

5. Cytogenetics is a field of study that deals with chromosomes and related abnormalities. Chromosome analysis is also known as karyotyping and involves the pairing of homologous chromosomes. Cytogenetic analysis is very crucial in the diagnosis of oncologic and hematologic disorders. A translocation involving chromosomes 15 and 17 referred to as t(15;17) is linked to acute promyelocytic leukemia (APL), which is a distinct AML subtype.

6. Based on the laboratory examination the patient is having cute promyelocytic leukemia (APL), which is a distinct AML subtype.

7. For antigen CD10 the monoclonal antibody is J5

For antigen CD13 the monoclonal antibody is  My7

For antigen CD33 the monoclonal antibody is My9

For antigen CD34 the monoclonal antibody is HPCA-1

For antigen CD11b the monoclonal activity is Leu-15

For antigen CD14 the monoclonal antibody is My4

For antigen Glycophorin A the monoclonal antibody is BMA0160

For antigen HLA-DR the monoclonal antibody is OKDR

8. There is an alteration in the coagulation factors associated with platelet count for the patient results in excessive bleeding

9. Around 90 percent of people with an AML type known as acute promyelocytic leukemia (APL) will go into remission after “induction” (first round) of chemo. This is according to the American Cancer Society (ACS). For most other types of AML, the remission rate is around 67 percent..