Chronic lymphocytic leukemia, peripheral smear.

90% of CLL cases occur in patients over 50 years of age. Picture perfect autoimmune hemolytic anemia (schistocytes, spherocytes, DAT positivity) presents in 15-35% of cases. Patients tend to survive for a very long time (5-20 years), and unlike CML, there is no blast crisis and they usually die of some other infection.

Its main hallmark is absolute lymphocytosis, and the lymphocytes have very clumpy chromatin that makes them look like soccer balls (alternatively, they all just break and you get a slide full of smudge cells). It’s extremely easy to pick out once you’ve seen it since, by lymphocytosis, I mean I had a patient today with a white cell count of 549x10^9/L (high normal is 11x10^9/L for our region). 

Larval Echinococcus granulosus, light micrograph.

Let’s do another story.

There was a cancer patient who had one day, in the middle of her chemo, discovered a mass in her breast. Thinking this was a tumor, the doctors decided to go in and do a biopsy. The surgeon cut just a little bit below the mass, expecting to do a regular biopsy, when a hydatid cyst full of tiny dog tapeworm larvae explodes out of the incision. The surgeon freaks out and sucks most of them up but manages to save enough to send to the lab to make a diagnosis.

What the heck? Let’s look into the history.

Not too long ago, her dog had died of unexplained seizures (no autopsy). Turns out, she had been in Aruba not too long ago and one of the two got infected and passed it on. When she went onto chemotherapy, it knocked out her immune system enough that the parasite began to flourish.

Acute Erythroblastic Leukemia, peripheral smear.

AEL is incredibly hard to miss when it comes up on a smear. Like all AMLs, it is a malignant expansion of precursor cells—in this case, red blood cell precursors. When doing a cell differential, the nucleated red cells are hugely elevated (by which I mean you can easily have more nucleated red cells than all the white blood cells combined where there should be very few if any in a normal smear).

Let me tell you about my most interesting bone marrow collection.

Here, the way they are done is a pathologist does the collection and the technologist assists them by setting up his tray, injecting the syringes full of aspirate into the correct tubes before they clot (some pathologists like to throw them at you; that is gross), and making smears, etc. 

The patient was a sternal collection. It was also rock solid there and the pathologist had to climb on top of her and was all but drilling the needle into her chest. Even when it is soft, this is a horrible thing to witness when you are a patient and that is partially why we normally collect from the posterior. We also couldn’t get a trephine out at the end because the marrow itself was so soft, so we ended up tapping two more holes.

The first EDTA also partially clotted and we needed another aspirate which was so hard to pull, it clotted before they could even unload the syringe and we decided to make do with what we could because it would only get harder from there.

In the meanwhile, the patient had a reaction to the anesthesia and vomited.

Once in a while we get thrown a curve ball and get specimens from people who don’t need any clinical direction anymore.

Today, I received a vitreous fluid specimen from a 15 year old boy who was killed in a bike accident—a huge bummer in and of itself. They wanted to know if alcohol was involved.

Basically, eyeball fluid is a good specimen for post mortem ethanols because the levels are pretty stable and bacteria don’t have an easy time mucking things up in there (as they tend to in a lot of specimen types).