Hematology Morphology Critique

Survey Slide:

07-11-S

History:

60-year-old female presenting with pneumonia

Further Laboratory Data:

Hgb
RBC
Hct
MCV
MCH
MCHC
RDW
WBC
Platelets

:
:
:
:
:
:
:
:
:

Reticulocyte count

90
2.92
0.25
87
30.8
355
17.7
2.3
34

g/L
1012/L
L/L
fL
pg
g/L
%
109/L
109/L

30 109/L

WBC Differential

Neutrophils
Lymphocytes
Monocytes
Plasma cells

Relative (0.00)

Acceptable Range (3 SD)

Absolute (x 109/L)

0.36
0.48
0.08
0.08

0.22-0.49
0.05-0.91
0.00-0.19
0.00-0.47

0.8
1.1
0.2
0.2

Morphology:
RBC:

There is a moderate normochromic, normocytic anemia with an increase in rouleaux

formation and a rare nucleated red blood cell noted. Polychromasia does not appear
increased.

WBC:

The total white blood cell and absolute neutrophil count are both low with a large number of
plasmacytoid cells present.

Platelets:

Platelets are present in markedly decreased numbers with normal morphology.

ALQEP Morphology Critique 07-11-S

Copyright 2007 College of Physicians and Surgeons of Alberta

CPSA: November 2007

Page 1 of 5

Hematology Morphology Critique

07-11-S
Conclusion:
This slide was taken from a patient with a history of plasma cell myeloma who presented to the hospital
with pneumonia. As is often seen with myeloma patients, there is a moderate normochromic,
normocytic anemia with rouleaux formation. The total white cell count is low, with approximately 40% of
the circulating white cells appearing as abnormal plasmacytoid cells with prominent nucleoli. These
could be considered abnormal plasmacytoid lymphocytes or circulating myeloma (plasma) cells. The
finding of plasma cells in the peripheral blood is a rare finding regardless of the underlying disorder.
A normal plasma cell is a mature B lymphocyte that is specialized for antibody (immunoglobulin)
production. When neoplastic cells are found in circulating blood as in this case, it is termed plasma cell
leukemia. Usually plasma cells in this setting are abnormal with prominent nucleoli.Plasma cells are
rarely found in the peripheral blood and comprise from 0.2% to 2.8% of the normal bone marrow
differential.
Mature plasma cells are often oval or fan shaped, measuring 8-15 m. The nucleus is eccentric and
oval in shape. The nucleus to cytoplasm ratio is typically 2:1 to 1:1. The perinuclear zone is very
distinct, appearing white in the deeply basophilic cytoplasm. Nuclear chromatin is condensed and very
patchy, appearing as dark blocks on a reddish-purple background. As the blocks of chromatin may be
distributed at the periphery of the nucleus, plasma cells are sometimes said to have a clock-face
nucleus. The cytoplasm stains deep blue to gray blue, depending on the stain and the ribosomal
content of the individual cell. Plasma cells are seen in increased numbers in multiple myeloma, plasma
cell leukemia, Waldenstrm's macroglobulinemia, and MGUS (monoclonal gammopathy of uncertain
significance). A marrow plasmacytosis may also be seen in certain benign conditions such as chronic
infection.
Multiple myeloma and plasma cell leukemia are disseminated plasma cell neoplasms. Multiple
myeloma is characterized by the proliferation of myeloma cells in the bone marrow and the secretion of
a monoclonal immunoglobulin or immunoglobulin light chain (paraprotein). The monoclonal
immunoglobulin is detectable in the serum while the monoclonal light chain, being of low molecular
weight is excreted in the urine (Bence-Jones protein). In the majority of cases in which there is a serum
paraprotein there is also increased background staining and increased rouleaux formation. In some
patients with multiple myeloma, the paraprotein is a cryoglobulin or has cold agglutinin activity. In these
cases, precipitated cryoglobulin or red cell agglutinates may be noted on the blood film. Cold
agglutinins or cryoglobulins may also cause factitious results with automated cell counters.
Rouleaux is best detected using a low power (10X) scan of the peripheral blood film. A review at low
power reveals the characteristic stack of coins appearance of red cells, even in the thin edge of the
blood film. If the rouleaux extends to the tails of the film it would be considered marked as in this
case.

ALQEP Morphology Critique 07-11-S

Copyright 2007 College of Physicians and Surgeons of Alberta

CPSA: November 2007

Page 2 of 5

Hematology Morphology Critique

07-11-S
Figure 1: Plasma cell3

Morphological Diagnosis:
Marked Thrombocytopenia (with Normochromic/normocytic anemia, rouleaux and circulating
plasmacytoid lymphocytes)
Significant Diagnostic Features:
Markedly decreased platelets
Rouleaux
Plasmacytoid lymphocytes / Plasma cells / Plasma blasts
Summary of Results:
07-11-S
Acceptable
Acceptable with review
Unacceptable
Not Received

:
:
:
:

65
58
9
1

References:
1. Glassy, Eric F., ed. - CAP Hematology and Clinical Microscopy Resource Committee. Color Atlas
of Hematology. 1998; 235; 242-243
2. Bain, Barbara J. Blood Cells A Practical Guide. Third Edition. 2002; 105-106; 379-380
3. http://image.bloodline.net/stories/storyReader$706

ALQEP Morphology Critique 07-11-S

Copyright 2007 College of Physicians and Surgeons of Alberta

CPSA: November 2007

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Hematology Morphology Critique

07-11-S

Grading Criteria:
Accepted without downgrading:

Reporting relative differential values > 3SD for blasts in presence of plasma/lymphoma or
abnormal lymphocytic cells

Reporting relative differential values > 3SD for myeloid precursors (0.01-0.05)

Reporting moderately decreased platelets (51-100 X 109/L)

Reported critically decreased platelets (<30 X 109/L)

Reporting reactive lymphocytes as well as the presence of plasmacytoid lymphocytes

Not reporting toxic changes

Reporting abnormal granulation excluding toxic

Reporting Pappenheimer bodies

Reporting hypersegmented neutrophils

Reporting autoagglutination

Reporting dimorphic picture

Reporting target cells

Reporting tear drop cells

Reporting schistocytes

Reporting spherocytes

Reporting ovalocytes

Reporting macrocytes (oval or round)

Reporting hypochromia

Reporting microcytes
Acceptable with Review grades (AR) assigned for:

Reporting reactive lymphocytes only with no indication of abnormal or plasmacytoid

lymphocytes

Not providing absolute values

Reporting total absolute count that does not add up to given or corrected WBC count

Relative differential values > 3SD (except where noted)

Relative count out by .01 -.03 (.97 - 1.03)

Reporting polychromasia (only 14% of respondents and 5% of reference technologists reported)

Not reporting rouleaux

Unacceptable (U) Grade assigned for:
Relative count out by .01 -.04 (.96 - 1.04)

Reporting relative differential values > 3SD for blasts without presence of plasma/lymphoma
or abnormal lymphocytic cells

Reporting a normal differential with no indication of any abnormal / reactive or plasmacytoid

lymphocytes

ALQEP Morphology Critique 07-11-S

Copyright 2007 College of Physicians and Surgeons of Alberta

CPSA: November 2007

Page 4 of 5

Hematology Morphology Critique

07-11-S
Diagnostic Features Reporting Frequency:
(Highlighted codes represent significant diagnostic features)

Reporting Codes
RBC

% Reporting

101
104

Normal
Polychromasia

18.2
14.4

115

Rouleaux

71.2

Toxic changes
Reactive/atypical lymphocytes
Other Leukocyte Abnormality
Plasma/Lymphoma/Abnormal lymphocyte cells

86.4
48.5

Markedly decreased (20-50 X 109/L)

88.6

WBC
210
206
211

43.9

Platelets
306

Referral to Pathologist
97.0

ALQEP Morphology Critique 07-11-S

Copyright 2007 College of Physicians and Surgeons of Alberta

CPSA: November 2007

Page 5 of 5