Myelodysplastic Syndrome (MDS) Case Study adapted from Clinical Laboratory Haematology

(2010) McKenzie and Williams Pearson Education, Inc.

CASE STUDY
Hancock, a 65 year-old Caucasian male, was seen by his physician with complaints of
fatigue, malaise, anorexia and hemoptysis of recent onset.

A CBC was ordered revealing the following; noteworthy was the documentation of
haematopoietic cells showing dysplasia.

RBC Count 1.60 x 1012/L WBC Count 3.5 x 109/L

Hb 5.8 g/dL Neutrophils 44%
Hct 0.17 L/L N. Bands 7%
Platelet Count 39 x 109/L 1N. Metamyelocytes 1%

Reticulocyte Count 0.8 % N. Myelocytes 1%

Monocytes 6%
Eosinophils 28%
Promyelocytes 9%
Blasts 4%

The Wright’s stained peripheral smear was made and the electron photomicrographs
provided (A and E) were obtained from the appropriate areas of the smear (x 100
Magnification).

The dysplastic changes seen refer to the following:

A
B

1) Hyposegmentation for example Pseudo Pelger-Huet anaomaly (see A and C) or

indistinct nuclear chromatin separation (see B and E).
2) Hypogranulation of granulocytes (see A and C).
3) Hypogranulation or Agranulation of Platelets (see D and E).
C
Notation:
Of the 44%
Neutrophils seen in
the WBC
Differential,
approximately 15%
demonstrated this
morphology.

Questions:
Is this a mature cell?

What phrase comes

to mind when
describing this cell?
 D
Notation:
Look at the four (4)
platelets in this hpf.

Question:
Describe the
platelets.

Normal sized RBC

Questions:
Describe the
morphology of the
RBCs seen in these
two pictures.
E

Does the RBC

morphology
compare with that
of the RBC Indices
calculated?

Notation:
This is a Platelet!

Hypogranular Platelet

Questions:
Question 1:    What terminology can be used to describe the cells counted on the automated
WBC Differential? (1 mark)
Question 2a:   Calculate the absolute values for the granulocytes & lymphocytes. (2 marks)
Question 2b:   Calculate and comment on the RBC Indices. How do the Indices compare with
the RBC Morphology demonstrated? (3 + 2 = 5 marks)

Question 3a: The attending physician is asking your opinion as it pertains to this patient.
State three (3) disorders (RBC and/or WBC Disorders) that can result in similar
blood cell counts as seen documented here. (3 marks)

Question 3b:   For the three disorders stated in part 3a, use the clinical picture, CBC and WBC
Differential values to discuss the similarities with this case study.
(3 x 3 = 9 marks)

Question 4:   Give at least four (4) other examples of dysplastic changes. (4 marks)

2
Question 5: Based upon the information given predict the RDW value for this patient.
Justify your response. (1 + 2 = 3 marks)

CASE STUDY cont’d

Bone marrow studies were performed on Hancock.

Bone Marrow Report:

The marrow showed hypercellularity with 9% blasts, 26% Promyelocytes, 18% N. Myelocytes,
6% N. Metamyelocytes, 4% N. Bands and 37% Eosinophils.
The M:E ratio was 12:1.
The N. Myelocytes were hypogranular with some displaying bi-nucleate forms.
The erythroid precursors showed megaloblastoid changes.

Questions cont’d:
Question 6:    What does the M:E ratio indicate? (2 marks)

Question 7: The attending physician requests your input regarding the necessity to do
Vitamin B12 and Folate levels.
Use the information presented thus far to give a response (with justification).
(1 + 3 = 4 marks)

Question 8a: Review all of Hancock’s results thus far. Which category of MDS do you suspect
to be present here (give justification). (1 + 2 = 3 marks)

Question 8b: What other test(s) would be essential in confirming your suspicion in part 8a?
Give the expected results for the MDS category suspected.
(4 + 4 = 8 marks)

Question 9a: Link the peripheral blood cell counts with the cells’ apoptotic rate
in Myelodysplastic Syndromes (MDS). (4 marks)

Question 9b: How does the mechanism of gene mutation in MDS facilitate the
pathophysiology documented? (5 marks)

CASE STUDY cont’d

Hancock’s treatment was symptom-based as efforts to obtain a compatible donor for bone
marrow transplantation were fruitless. Hancock was treated on an out-patient basis. It was on
one such occasion when Hancock returned that the following was noted:
WBC Count 10.5 x 109/L

Neutrophils 50%
N. Bands 4%
N. Metamyelocytes 2%
N. Myelocytes 5%
Monocytes 2%
Promyelocytes 12%
Blasts 25%

Question 10a: What is the most likely explanation for Hancock’s presentation at this point?
Give justification for your response. (1 + 2 = 3 marks)

Question 10b: Elaborate upon the expected bone marrow findings at this point. (4 marks)