Blood Hematopoietic Disease :Examination of peripheral blood and bone marrow in blood diseases
• Visual contact is important in the examination of peripheral blood.
In CBC test (RBC, Hb, Ht, WBC, Blood platelet count), not only hematology but also pulling peripheral blood smear and reading smear by visual contact are important.
- When it is unable to pull smear well in room temperature, possibility of cold agglutinin disease (CAD), which has high cold agglutinin value, is high.
- When RBC rouleaux formation (fig.1) can be seen on the smear, there is a possibility of high IgM hyperviscosity syndrome like Primary Macrogrobrinemia.
- At each observation of RBC configuration, existence or non-existence of poikilocyte is observed. Especially, inherited hemolytic anemia is suspicious from spherocyte, elliptocyte and stomatocyte, obstructive icterus or biliary obstruction (bile stasis) is suspicious from leptocyte (target cell), bone marrow fibrosis is suspicious from dacryocyte (tear-drop cell), and thrombus-thrombocytopenia purpura (TTP) or hemolytic uremic syndrome (HUS) is suspicious from shistocyte. (fig.2)
- The detail of lymph corpuscle configuration has no choice but to depend on eye contact. Lymph corpuscle is separated into Normal lymphocyte, lymphoblast, atypical lymphocyte and abnormal lymphocyte. It is easy to differentiate lymphoblast and atypical lymphocyte, but it is rather difficult to differentiate abnormal lymphocyte and normal lymphocyte which can be seen in adult T-cell leukemia (ATL), chronic lymphocytic leukemia (CLL), hairy cell leukemia (HCL), or T-cell large granular leukemia. When it is not possible to diagnose from morphological observation, flow cytometry (especially when there is remarkable difference in the appearance of kappa chain and lambda chain in B lymph corpuscle, it can be diagnosed as abnormal lymphocyte) examination is recommended. At the same time, try not to forget about asking chromosomal inspection of peripheral blood. It is known that ATL-like cell may appear even in pertussis, so that it may lead to the diagnosis.
- Abnormality of Neutrophil configuration
- In bone marrow dysplasia syndrome (MDS), neutrophil indicating false Pergel nuclear anomaly as Low-leaf nuclear anomaly can be seen. And in Vitamin B12 deficiency Big PRCA anemia, hyper-segmented neutrophil can be seen. In WHIM (Warts, hypo-gammaglobulinemia, infections, and myelokathexis syndrome) syndrome, overgrowth neutrophil (aspect is condensed nuclear and vacuole cytoplasmic morphology connected by long and arced fiber) is seen. In May-Hegglin disease, one of MYH9 abnormal disease, inclusion body in the neutrophil reticulum can be seen. In Chediak-Higashi Syndrome (CHS), giant granule exist in cellular.
- Blood Platelet Size
- The volume of blood platelet is well analogized by smear observation, but as mentioned in thrombocytopenia section, the size of blood platelet should be paid more attention. There are with reduced blood platelet number type and without reduced blood platelet type in the inherited thrombocytopenia. But especially in MYH9 Abnormal disease (May-Hegglin syndrome, Epstein syndrome), large platelet thrombocytopenia is characterized in which the size of blood platelet is larger than normal size. On the other hand, in Wiskott Aldrich syndrome (WAS), smaller platelet size is the characteristic in addition to the reduced blood platelet number.
• It is recommended to conduct Bone marrow test from iliac.
Bone-marrow examination is necessary for all blood diseases. Normally, bone puncture is performed, but in many cases, biopsy is requested. At this moment of time, it is recommended that the bone puncture (biopsy) should be performed from iliac bone side instead of breast bone. In Bone Puncture, it is important affair not only to have the observation of smear, but also flowcytometry examination for puncture fluid, chromosomal test, or to customary present for the clot sample preparation. Pathological examination of clot sample becomes the supplement to bone-marrow smear observation. When necessary, pathological tissue biopsy of clot sample can be used for EBER-ISH examination which investigate for immunostaining or EB virus infection disease. Information from smear observation is not so much, with utilizing one-time examination sample at most, definitive diagnosis is made with performing comprehensive evaluation for all this information. The same is applied to the biopsy of lymph node. (fig.3)
- Special Staining for Smear; Myeloperoxidase, Esterase, PAS, Iron Staining, there are many methods available so that it is not necessary for all bone-marrow sample to have all these special staining. They are selected appropriately for the target disease.
- Problem of Dry Tap at Bone-marrow puncture: It is called as Dry Tap when puncture fluid is unable to pull out at bone-marrow puncture. This is a problem of either; puncture needle is properly reached to bone-marrow but unable to pull fluid out, or needle does not reach to bone-marrow due to the technical reason. Bone-marrow biopsy is performed to diagnose Bone marrow fibrosis. Even if in Dry Tap, to test the few drops of bone-marrow fluid on top of puncture needle, diagnosis of leukemia can be reached. So that even with few drops of sample, it is critically important to observe them with utmost care.
Fig.1 Rouleaux formation in over-viscosity syndrome
Fig. 2 Spherocytosis (A), Elliptocytosis (B), Stomatocytosis (C)
Fig.3 Examination procedure for Bone-marrow Examination, Lymph node Biopsy