White blood cell differential fluorescence abnormal scattergram: A useful indicator for early detection of malarial parasite

Background & Objective: Undiagnosed malarial infectionis associated with significant mortality and morbidity. Laboratory investigations leading to rapid, accurate and timely diagnosis of malaria is still a challenge. This study was done to assess the utility of abnormal White blood cell differential fluorescence (WDF) scattergram for diagnosis of malaria. Our aim was to study the utility of WDF scattergram for early detection of malarial parasite. Methods: All EDTA anti-coagulated blood samples received in laboratory during a period from Dec 2019 to May 2020 were analyzed on anautomated hematology analyzer, Sysmex XN 1000. All abnormal WDF scattergrams pertaining to plasmodium specie were critically evaluated and recorded. Review of Leishman-stained peripheral smears as well as immune-chromatographic assay by rapid test devices (RTD) was done. Accordingly, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detection of malaria by abnormal scattergram were calculated. Results: Out of total 1, 26,000of samples analyzed, abnormal WDF scattergrams were detected in 96 cases. Amongst these, 95.8% (92) were positive for MP on Leishman-stained peripheral smear as well as on ICT with a p-value of 0.05. WDF scattergram abnormalities typical of malaria showed a sensitivity of 80% and specificity of 93.26%. Positive predictive value of 95.8% whereas negative predictive value of 99.9% was detected. Significant findings of hemolysis, platelet clumps, nucleated RBCS (NRBCs) and RBC agglutination were noted in cases (n=4) with abnormal WDF scattergram negative for malaria on peripheral smear. Conclusion: Interpretation of abnormal WDF scattergram not only increases the early detection rate for malarial parasite but isa strong indicator for presence of hemolysis, RBC agglutination, platelet clumps and leucoerythroblastic blood picture as well. doi: https://doi.org/10.12669/pjms.38.3.4702 How to cite this:Rehan M, Khalid A, Nasreen F. White blood cell differential fluorescence abnormal scattergram: A useful indicator for early detection of malarial parasite. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.4702 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pseudoeosinophilia with Abnormal WBC Scattergram: an Important Diagnostic Clue on Hematology Analyzer

Malaria is one of the most common parasitic diseases causing a significant burden on health care, especially in India. Light microscopy, the gold standard for malaria diagnosis is time-consuming especially in a setup where the caseload is high and parasite index is low. Knowledge of abnormal scattergrams by the malarial parasite is very essential to suspect malaria and screen those cases thoroughly on a peripheral smear for accurate diagnosis. A timely and accurate diagnosis is crucial to the prognosis of this disease. Herein, we report a case of a 40-year-old male from Punjab who presented to the emergency with fever and an altered sensorium. Analyzer showed characteristic pseudo eosinophilia with greying of neutrophil eosinophil zone with double eosinophil cluster. According to flagging rules because of eosinophilia, peripheral blood film (PBF) was made and examined, which revealed Plasmodium falciparum gametocytes.

Morphological Changes in Blood Cells as Indicators for Disease Progression in COVID 19

A novel highly pathogenic human corona virus (COVID19) has been recently recognised in Wuhan, China as the cause of corona disease outbreak. It has rapidly spread from China to various countries across the world evolving as a pandemic. In our study we have categorized the covid positive patients into mild, moderate and severe based on the clinical criteria suggested by WHO. The coagulation parameters of the patients were analysed and documented. A peripheral smear was made for every patient and the morphological changes in blood cells were documented. The peripheral smear findings were then correlated with the disease stage and coagulation parameters. There were significant differences in the total WBC count and the differential WBC count between stages 1 &2 and stages 1 & 3 (p<0.005). Leucocytosis, neutrophilia and toxic changes in neutrophils were seen in severe stage of the disease and in covid coagulopathy suggesting these are important indicators of disease severity. Schistocytes an important finding in any other coagulopathy was not present in covid associated coagulopathy. Activated lymphocytes was found to be the most common morphological presentation seen in all covid patients irrespective of the disease stage whereas plasmacytoid lymphocytes was an important finding in severe stage disease. Monocyte cytoplasmic vacuoles, large/giant platelets were other morphological findings observed but these findings did not have any significant correlation with disease stage. Since follow up smears of the same patient were not analysed during disease progression and also post recovery, additional research in this field will provide further insights.

Blastic Plasmacytoid Dendritic Cell Neoplasm: A Rare Case Report with Literature Review

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematopoietic neoplasm for which there are no effective therapies. We present a 70-year-old male patient with multiple reddish painless, nonpruritic, and nonpedunculated nodules over the trunk, forearm, and thighs for a duration of 3 months. The nodules measured 0.5 to 2 cm in diameter. The peripheral smear findings were within normal limits. Excision biopsy was performed. Histomorphology and immunohistochemistry (CD123, CD 56, CD4, HLA-DR, CD43, and CD68) confirmed the diagnosis of BPDCN. Findings of marrow aspiration, biopsy and imaging studies were within normal limits. Patient demonstrated a good response with complete disappearance of all nodules by initial 2 weeks of therapy with a modified Berlin–Frankfurt–Munster (BFM) acute lymphoblastic leukemia (ALL) protocol and has completed 8 doses (LSAP [lincosamides, streptogramins A and pleuromutilins chemotherapy], 5,000 units/m2). The patient tolerated protocol extremely well.

Case Report on Cirrhosis of Liver

Liver is the second largest organ in human body, more than 5,000 separate bodily functions .including helping blood to clot, cleansing the blood of toxins to converting food into nutrients to control hormone levels, fighting infections and illness, regenerating back after injury and metabolizing cholesterol, glucose, iron and controlling their levels. A 56- years old patient was admitted in AVBRH on date 9/12/2020 in ICU with the chief complaint of abdominal distension, breathlessness on exertion, pedal edema, fever since 8 days. After admitted in hospital all investigation was done including blood test, ECG, fluid cytology, peripheral smear, ultrasonography, etc. All investigation conducted and then final diagnosis confirmed as cirrhosis of liver. Patient was not having any history of communicable disease or any hereditary disease but he has history of hypertension and type II Diabetes mellitus for 12 years. Patient was COVID-19 negative and admitted in intensive care unit. Patient had been undergone with various investigations like physical examination, blood test, CSF fluid examination, ascitic fluid examination, fluid cytology, peripheral smear, ultrasonography, RT-PCR etc. Patient was treated with tab. farobact ER 300 mg BD, tab. Lasix 40 mg OD, tab. Udilive 300 mg BD, tab. Rifagut 300 mg BD, tab. Metformin 500 mg OD, tab. Amlo 5mg OD, syp. Duphalac 30ml HS. Monitor vital signs, maintain input output, Monitoring and managing potential complications like, bleeding and haemorrhage, hepatic encephalopathy, fluid volume excess, monitor laboratory tests as indicated, Identify and assess for pedal edema. Conclusion: Cirrhosis of the liver is one of the final stages of liver disease. It is a serious condition, causing scarring and permanent damage to the liver. Life expectancy depends on the stage and type of cirrhosis of liver. Cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function (decompensated cirrhosis). Advanced cirrhosis is life-threatening. If liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

Case Report on Acute Lymphoblastic Leukemia B-Cell

Introduction: B- Cell lymphoblastic leukaemia of blood cancer that influences B- Lymphocytes, which are white blood cells that create within the delicate marrow of your bones (marrow) [1]. When healthy blood cells start to alter and expand out of control, this is called leukaemia. ALL is a tumour of immature lymphocytes. Lymphocytes are white blood cells that help the immune system function. Acute lymphoid leukaemia (ALL) is also known as acute lymphoblastic leukaemia. ALL is most visits in youthful children and people over the age of 50, but it can influence anybody at any age [2]. Aim: To acquire the knowledge regarding a case of B-cell acute lymphoblastic leukaemia. Clinical findings: Abdominal discomfort, fever high grade, chills, Weakness. Diagnostic Evaluation: Blood Test: Hb-5.5%, Total RBC count-2.21million/cu.mm, Total WBC count- 27400/cumm, RDW- 14.8%, HCT-17.7%, Monocytes-02%, Granulocytes-28%, Lymphocytes-68%, AST(SGOT)-110U/L. Peripheral Smear: RBC: Total RBC Count- Decreased on smear, Haemoglobin- Decreased Predominantly normocytic with few micro showing moderate lymphomia, Platelets- Decreased on smear No hemoparacites are seen, Peripheral smear is suspicious of severe viral infection. Ultrasonography: Splenomegaly. Bone marrow aspiration and biopsy. B-cell lymphoblasts (immature white blood cells) are found in the bone marrow Therapeutic intervention: Blood Transfusion-30 times, Inj Levofloxacin, Inj. Piptaz, Inj. Pan, Inj. Emset, Inj. Doxy, Inj. Hydrocort, Inj. Avil, Tab prednisolone, Tab Dolo. Outcome: After Treatment, The patient shows improvement. His fever and abdominal discomfort were relived and his Hb% increased from 5.5% to 6% after blood transfusion. Conclusion: B-cell acute lymphoblastic leukemia is one of the most common types of leukemia in children but is rare in adults. My patient was admitted to medicine ward no-30, AVBRH with diagnosed of Acute Lymphatic Leukaemia and he had complaint of fever and abdominal discomfort. After getting appropriate treatment his condition was improved.

Improving Residents' Knowledge of Peripheral Smears

Background: A peripheral smear is an important diagnostic tool, inexpensive, reliable and quick. It reflects the functional status of the bone marrow and can identify many blood disorders, some of which are life threatening and very time sensitive. Peripheral smears are useful to assess cytopenic states (eg, anemia, leukopenia, thrombocytopenia) or identify hematologic emergencies such as thrombocytopenic purpura/hemolytic uremic syndrome, acute myeloid leukemia, and disseminated intravascular coagulation etc. Sometimes it is sufficient to make a diagnosis solely based on them which can be life saving when time is of the essence. Based on our literature search, there are no studies to assess internal medicine residents' knowledge and understanding of peripheral smears. Methods: We created a multiple-choice questions survey of 13 questions for residents to fill out, involving common findings on peripheral smears and those found in hematologic emergencies that every resident should be aware of. Response rate in all three program years (PGY) was 100%. 16/16 PGY-1, 10/10 PGY-2 and 9/9 PGY-3 completed the survey. Results: Average pre-intervention score for PGY-1 was 42%, PGY-2 was 34% and PGY-3 was 30%. Questions most commonly wrong were regarding target cells, metamyelocytes, giant platelets and schistocytes. Most were correct about microcytosis and Auer rods. We then conducted the same survey weeks after our intervention, which was interactive, small group didactics sessions on peripheral smears. We compared results of the survey before and after didactics to check for improvement. Post-intervention score for PGY-1 was 98%, PGY-2 and PGY-3 were 96%. Conclusions: Most medical residents are not aware of common interpretations of peripheral smears and this does not seem to improve with each progressive year. Improving residents' knowledge of peripheral smears is a cost effective and quick measure that can improve patient care, in addition to potentially improving internal medicine board results. In the future, we aim to make a curriculum for peripheral smear review for residents. We can compare results of the survey with hematology oncology fellows. Disclosures No relevant conflicts of interest to declare.

New segmentation and feature extraction algorithm for classification of white blood cells in peripheral smear images

This article addresses a new method for the classification of white blood cells (WBCs) using image processing techniques and machine learning methods. The proposed method consists of three steps: detecting the nucleus and cytoplasm, extracting features, and classification. At first, a new algorithm is designed to segment the nucleus. For the cytoplasm to be detected, only a part of it located inside the convex hull of the nucleus is involved in the process. This attitude helps us overcome the difficulties of segmenting the cytoplasm. In the second phase, three shapes and four novel color features are devised and extracted. Finally, by using an SVM model, the WBCs are classified. The segmentation algorithm can detect the nucleus with a dice similarity coefficient of 0.9675. The proposed method can categorize WBCs in Raabin-WBC, LISC, and BCCD datasets with accuracies of 94.65%, 92.21%, and 94.20%, respectively. Besides, we show that the proposed method possesses more generalization power than pre-trained CNN models. It is worth mentioning that the hyperparameters of the classifier are fixed only with the Raabin-WBC dataset, and these parameters are not readjusted for LISC and BCCD datasets.

Japanese Encephalitis with Global Aphasia- A Case Report

Introduction: Japanese Encephalitis (JE) is a brain infection caused by the Japanese Virus of Encephalitis (JEV).JE is also known as Mosquito-Borne Encephalitis, Summer Encephalitis and Brain Fever etc. Global aphasia is caused by a number of factors, one of which is JE. Presentation of Case: A 15 years old male child was brought to Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, Maharashtra, India on date 22/08/2019 with complaints of fever since 7 days with 2 episodes of seizures with loss of consciousness for approximately 20 hours and the patient was unable to speak after becoming conscious. On examination, the patient had a fever, was lethargic and appeared depressed, unable to speak, and experienced pain when moving his hands. The patient had a complete blood count, which revealed that his haemoglobin percent, total red blood count, were all low, while his RDW and granulocytes were high. RBCs are predominantly normocytic Normochromic RBCs with mild anisopoikilocytosis, with a few microcytic RBCs, pencil cells, and tear drop cells visible on a peripheral smear as well as platelets were adequate, and no Hemiparasite was found. CSF analysis, CT scan of the brain, an MRI of the brain, and a blood test for P. Falciparum were all performed for diagnostic purposes. The patient was diagnosed as Japanese Encephalitis with Global Aphasia after comprehensive examinations. He was treated Tab. Cefexime, Tab. Levetiracetam, Tab. Phenytoin, Tab. Paracetamol, and Tab. Emset, as well as nursing care was provided based on his needs. Conclusion: Patient showed spontaneous recovery.