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Anon left asks about this in rapid succession, so I guess that is my cue to talk about megaloblastic anemia, haha.
Megaloblastic anemia is a non-hemolytic anemia, usually attributed to either B12 deficiency (impaired absorption because of a gastrectomy, pernicious anemia, inflammation, or transcobalamin deficiency) or Folate deficiency (dietary, drug related impairment of use, loss though kidney). Both are cofactors in DNA synthesis, especially of thymidine. The result is nuclear cytoplasmic asynchrony wherein the nucleus matures slower than the cytoplasm, and you can see all the cells are a little off looking as a result.
In your smear, you won’t see much in the way of retics, but there will be extensive hypersegmentation of neutrophils, large platelets, huge macrocytes/macroovalocytes, tear cells, schistocytes, pancytopenia, and howell-jolly bodies. A few giant bands and metamyelocytes much sneak into the circulation too. Things are generally just. Big.
The bone marrow will have very distinct megaloblastic changees. The myeloid:erythroid ratio will be decreased but the marrow is almost always hypercellular. Very early erythroid precursors predominate over late precursors because of ineffective erythropoiesis. In contrast to the comically large myeloid precursors, megakaryocytes are small and hypolobated because they have so much DNA they are affected the most by impaired synthesis.
Burkitt’s Lymphoma, bone marrow touch prep + Wright’s stain
Extremely distinct, fairly uniform cells with super dark blue cytoplasm full of lipid vacuoles. It has an association with Epstein Barr virus, which is also the causative agent of infectious mono, hairy leukoplakia, and a whole host of other problems. What a tricky virus.
Trypanosoma sp in peripheral blood.
Trypanosomiasis which is spread by tsetse flies in a rather interesting way! After the fly bites someone, it defecates near the bite site and that is where this protozoan parasite can be found. The bite is painful and people smear said parasite into the wound when scratching it. The trypanosomes then spread to the nervous system, causing lethargy, tremors and confusion, and eventually coma and death.
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.
Allergy testing wasn’t something I learned in school, likely because the tests that exist right now are admittedly not very good. So when I ended up on the Allergy Bench I was a little bit boggled that there was a whole bench for it. Hopefully this will be an acceptable crash course in it.
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).
Diabetic nephropathy animation. Some time ago 3FX animation did a series of videos on diabetes. Check out their channel for more: http://www.youtube.com/user/3FXanimation
I figure at one point or another, I should stop posting so much about stool. (Wait until I post about a 72 hour fecal fat. Then you’ll be really jealous of my job haha, ick). So, here is a simple emergency room case study on a somewhat-elderly male. I probably won’t do very many of these at all, though.
Background: Immigrant, moved here almost 2 decades ago, living with a wife, daughter, and son-in-law with good family relationships and no major stresses. No suicidal ideations, but had a history of soap ingestion and a distant history of alcohol abuse.
He was brought to emergency by his son after he drank some Fleecy and Rug Doctor mixed in with some atarax and restoril (anti-anxiety medication) which apparently tasted like grapefruit juice. BP was 210/110, he was obtunded and close to a state of unconsciousness.