Photomicrographs and Color Plate Examination Refer to the photomicrographs and color plates that follow p. 544 1, Plate 1 is a photomicrograph of an antinuclear antibody test using human fibroblasts, fluorescein isothiocyanate (FIT'C)-conjugated antihuman Answers to Questions 1-2 1. A Using FITC-conjugated antihuman serum, difuse serum, and transmitted fluorescence microscopy. ‘Which pattern of immunofluorescence is demonstrated in this 400x field? ‘A. Homogenous 8. Peripheral €. Nucleolar D. Speckled Immunologylldentify microscopic morphology! Immunofluorescencel2 2, Plate 2 shows the electrophoresis of serum proteins on a high-resolution agarose gel at pH 8.6. Sample 1 (in lane 1) is a normal serum control. Which sample can be presumptively classified as a monoclonal gammopathy? ‘A. Sample 2 B. Sample 4 ©. Sample 6 D. Sample 8 Chemisery/Evaluate clinical and laboratory datal Protein elecorophoresisl3 apple-green Fuorescence seen over the entire nucleus characterizes the homogenous pattern. Ata significant titer, this pattern occurs in a variety of systemic autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and Sjogren's syncrome. [he antibodies are directed against nucleoprote'n; although they are mainly nonpathological, they are useful markers for active disease, ‘Amonoclonal gammopathy causes a band showing restricted electrophoretic mobilty usualy cated in the yor the f region. The band represents the accumulation of identical immunoglobulin molecules or fragments secreted by a malignant or venign clone of plasma ces. Confirmation ofthe band as immunoglobulin is required because other homogenous proteins (such as brinogen or arcinaembryonic an yen} can occur in the same 57538 Chapter 10| Phowomicrographs and Color Plate Examination 3. Plate 3 shows a densitometric scan of a control 6 serum for protein electrophoresis. The percentages of each fraction are shown below the scan. Given these results, what is the most appropriate initial corrective action? A. Repeat the electrophoresis run using fresh control serum, B, Report the results, provided that the previous sun was in control . Move the fourth fraction mark to the right and redraw the scan D. Calculate the concentration of each fraction in grams per deciliter Chemistrylldentfy sources of eroriDensitometryl3 Plate 4 shows the electrophoresis of serum proteins on a high-resolution agarose gel at pH 8.6. Which band represents the f lipoprotein? AA BB cc B.D ChemistrylEvaluate clinical and laboratory datal Protein electrophoresis!2 Plate 5 is a densitometric scan of a serum protein electrophoresis sample, The relative and absolute concentration of each fraction and reference limits are shown below the scan. What is the correct classification of this densitometric pattern? ‘A Polyclonal gammopathy associated with chronic inflammation B, Nephrotic syndrome . Acute inflammation D. Hepatic cirrhosis Chemistry/Bvaluate clinical and laboratory datal Protein elecorophoresisi3 Plate 6 shows an agarose gel on which, immunofixation electrophoresis (IFE) was performed at pH 8.6. Ihe gel contains the same serum sample as number 6 shown in Plate 2. ‘What is the heavy and light chain type of the monoclonal protein present in this sample? AlgAx B.IgG x CIgG A D.IgMA Chemistry/Evaluate clinical and laboratory datal Immunofixation electrophoresil3 3c 4c 5.C Answers to Questions 3-6 ‘The fraction matker between the a,-and fractions is marked improperly. High-resolution gels produce individual peaks for haptaglabin and a,-macraglobulin, which partally splits the ,-band into two subfractions. In addition, the Beband may contain three subfractions corresponding to B-ipoprotein, transferrin, and ‘complement, In this scan, the valley between the a, subfractions was selected incorrectly as the boundary between the o,-and Beractions. This fraction marker should be placed at the next valley tothe right and the scan redrawn to determine the area under the a,-and P-fractions correctly. Using high current. 8 lipoprotein can be separated from transferrin and complement (C3). B Lipoprotein migrates anodal tothe transferrin (band labeled D), and appears as a thin wavy band, C3 migrates ‘athodalto the transferrin band The band labeled Ais! antitrypsin and the band labeled 8 contains ‘0-2 macragloeulin and haptoglobin. The c=? macroglobulin is usualy anodal to the haptoglobin. This pattern is characterized by significant relative Increases in the o,-and 2,fractions and a decrease in sequm albumin concentration, Ths pattern is most often caused by increased production of acute phase reactants such 2s o,-antitypsin and haptoglobin that ae associated with acute inflammation. This pattern Is seen in myocardial infarction and other forms of acute tssue injury the earl stage of acute infection, and pregnancy IFEis performed by placing the patient's sample Inallsi lanes and separating the proteins by electrophotess, Following electrophoresis, the proteins in lane I are precipitated and fixed by verlaying sulfasalicylic acid onto the gel Monospecfic antiserum against each heavy or light chain's applied tothe gel aver the lanes as labeled and incubated to precipitate the immunoglobulins containing the corresponding chain. The gelis ‘washed to remove unpreciptated proteins then slained to visualize the precipitated bands. This FE {gel shows an insoluble immunoprecipitate restricted toa single band in lanes ? and 5, The proteins in lane 2 reacted with ante (antlgG},and the proteinsin Tane 5 reacted with anti-x Lane § also contains a faint restricted band anodal tothe IgG band. This band is not present in lane 2 (does not contain y chains) and represents free K ight chains,10. Plate 7 shows the electrophoresis of hemoglobin. (Fgh) samples performed on agarose gel, pH1 8.8. ‘The control sample is located in lanes 2 and 10 and contains Hgb A, S, and C. Which sample(s) are from neonates? ‘A. Samples 1 and 5 B. Sample 3 ©. Sample 7 D. Samples 8 and 9 Chemistry/Evaluate clinical and laboratory datal Hemoglobin electrophoresil2 . Plate & shows the electrophoresis of Hgb samples on acid agar gel, pH 6.0. The sample order is the same as for plate 7 with the A, S, C control hemolysate in lanes 2 and 10. Based upon the electrophoretic mobility of sample 7 as seen in both plate 7 and plate 8, what is the patient's Hgb phenotype? ASS BLAS CAD D.AG Chemistry/Evaluate clinical and laboratory datal Hemoglobin electrophoresil3 . Plate 9 is a photomicrograph of a fungal slide culture stained with lactophenol cotton blue, 400x. Which of the following fungi is present? A. Microsporum gypscum B. Microsporum canis Aspergillus niger D. Aspergillus fumigatus Microbiology/ Identify microscopic morphology/Fungil2 Plate 10 is a photomicrograph of a fungal slide culture stained with lactophenol cotton blue, 400x. Which of the following fungi is present? AM. gypseum B.M. canis ©. Trichophyton schoenleinit D. Epidermophyton floccosum MicrobiologyI Identify microscopic morpbology/Fungil2 ‘Chapter 10 | Photomicrographs and Color Plate Examination 539 Answers to Questions 7-10 7. A Neonates and infants up to 6 months old have 10. A D A Hab F levels between 8% and 40%. The “gb F level falls to below 29% n children over 2 yeats old. Hb F ismore acidic than Hgb and less acidic than Hb A. Therefore, at an alialine pH, Hgb F has a greater net negative charge than Hab 5 but a lesser net negative charge than Hab A, and migrates between Hab A and Hab S, Sample 7 demonstrates one major band on plate 7 in the Hab S position. Because Hab A 'snot present theres no normal -gene, and the patient can be dlassified as ahomazygote for Hgb 5, D,or G which migrate tothe same postion on agarose gel at 2 pH between 84 and 92. Hgb S can be differentiated from Hgbs D and G by performing electrophores's ‘on agar gel at pH 6.0-6.2. On agar at acid pH, Hgb C migrates furthest toward the anode, Hgb $ migrates toward she anode, but not as far as gb C. High F migrates furthest toward the cathode, while Habs A , Gand E migrate o the same position, slightly cathodal tothe point of application. On plate sample 7 shows 2 single large band that migrated ‘toward the anode atthe same position as the S band in the contral sample, A fumigatus produces hyaline, septate hyphae, ‘and dome-shaped vesicles, the upper one-half totwerthirds of which ate covered with a row of phialides producing long chains of canal. 4 niger proctuces spherical vesicles that are completely covered with phialdes. The philides produce jetblack conida that obscure the vesicle surface, forming 2 radiated head 1.gypseum and M canis produce septate macraconicia, not vesicles with phialides, M. gypseum produces enormous numbers of symmetric, rough macraconidia. These have ‘thin walls with not more than six compartments and have rounded ends. M, canis produces spindle-shaped macroconidia with usually more than six compartments and pointed ends. E floccosum forms macroconisia but not microconidia, The macroconidia are smooth and club shaped with rounded ends, Fach contains 2-6 cells and are found singly or in clusters Tschoenleini does nat prosuce macroconidia or microconidia and is identifieg by its hyphae-forming characteristis, I. schoenleini forms antler‘ike brancring hyphae called favie chandeliers540 Chapier 10| Phowomicrographs and Color Plate Examination 11. Plate 11 is a photomicrograph of a fungal slide culture stained with lactophenol cotton blue, 400x. The morphology is most consistent with which fungus? A Aspergillus spp. B. Penicillium spp. © Seedosporium D. Fusarium Microbiology/ Identify microscopic morphology! Mycolegyl2 12, Plate 12 is a bronchoalveolar lavage sample concentrated by eytocentrifugation and stained ‘with Wright's stain, 1,000x. The sample was obtained from a patient with AIDS who resides in the midwestern United States. Which infectious agent is present? A. Pheumocystisjiroveci (carinii) B. Mycobacterium aviumn-intracellalare ©. Histoplasma capsulatum D. Cryptococcus neoformans Microbiologyl Identify microscopic morphology! Mycolegy/2 13. Plate 13 is a fecal specimen seen under 40x using. brightfeld microscopy. The plate shows the ovum of which parasite? A. Necator americanus B. Trichuristrichiura ©. Ascaris lumbricoides D. Enterobius vermicularis Microbiologyildentify microscopic morphology! Parasites2 14, Plate 14 is a fecal specimen unstained seen under 40x using brightfield microscopy. The plate shows the ovum of which parasite? AN, americanus BT. erichiura CA. lumbricoides D.E. vermicularis Microbiology/ldentify microscopic morphology! Parasites? 15. Plate 15 is an iodine-stained fecal specimen seen under 400x using brightfield microscopy. The plate shows the ovum of which parasite? A. Pinworm B. Threadworm . Hookworm D. Whipworm Microbiology/ Identify microscopic morphology! Paraste!2 Answers to Questions 11-15 11. A This plate shows a fungus with thin, septate, branching hyphae. A conidiophore is presentin the center that contains a double raw of phialides producing round conidla, Fusarium spp. produces canoe-shaped macroconidia. These are made by phialides attached to the hyphae in the absence of Conidioohores. Penicium spp. produce conidia ftom a single row of phialdes that resembles a orush or the skeleton of a nang, Scedosporium spp, produce annelldes on short conidhophores with oval conidia that are tapered at one end. 12, € This plate shows abundant Histoplasma capsulatum (yeast phase) within the cytoplasm of both the macrophage and Fstiocyte All ofthe organisms Isted may cause pulmonary pneumonia in mmunedercient patients, Small oval yeast cell 2-5 pin diameter, are seen. 13, B The ova of I tichiura are brown and shaped like a football with mucus plugs at both ends. Ova have a thick wall and measure about 50 u long by 20 u wide. Enterobius ova are approximately the same size but have a clear (hyaline) shel, lat on fone side with 2 visible larva within, Necator eggs are larger (approximately 65-75 ji long by 40 4. wide) and have a clear shell 14. C Ascaris ova are large and oval, usually measuring 50-75 ui long by 35-50 u wide. They are often bile stalned and may have a thick shell with a coarse covering (conticated). This egg demonstrates a contracted embryo, leaving space between the shell and the emfryo at the opposing pales. Tis Indicates that the egg is fertlizes 15. C Hookworm ova are approximately 60-75 win length and 35~40 in width, They have a thin outer shell Usually containing an unembryonated or partly ‘embryonated egg within, The ova of Necator and Aneylostoma cannot be differentiated from one another. Tareadworm (Strongyloides) produces similar ova, bur these hatch inthe intestine, releasing the rhaoditoi larvae that are found inthe feces Pinworm (Enterabius) ova are approximately the same size but are more elongated and flat on one side. Waipworm (Iichuris ova are smaller and thick walled with mucus plugs at both ends.16, Plate 16 is an unstained fecal specimen seen under 400x using brightfield microscopy. The plate shows the ovum of which parasite? A. Clonorchis sinensis B. Fasciola hepatica €. Paragonimus westermani D. Fasciolopss bushi Microbiology/tdemtfy microscopic morphology! Parasites? 17, Plate 17 is an unstained fecal specimen seen under 40x using brightfield mieroscopy. The plate shows the ovum of which parasite? A. Fasciola hepatica B. Paragonimus westermani . Metagonimus yokogawai D. Opisthorchis viverrini Microbiology! Identify microscopic morphology! Paraste!2 18, Plate 18 is a peripheral blood film stained with Giemsa’s stain, 1,000x. What condition is suspected from this field? ‘A. Macrocytic anemia B. Agranulocytosis . Relapsing fever D. Lead poisoning Microbiology/ Identify microscopic morphology! Spirochetel2 19, Plate 19 shows an organism isolated from an eye wash of a patient with a cornea infection who had. been wearing contact lenses for the past 2 years. ‘What is the name of the causative agent? A. Naegleria spp. B. Acanthamoeba spp. ©. Entamoeba histolytica D. Trichomonas vaginalis Microbiology! Identify microscopic morphology! Parastes!2 20, Plate 20 is a Wright’s-stained peripheral blood film, 1,000x. Which malarial stage is present in ‘the RBC in the center of the plate? A. Ring «rophoroite of Plasmodium vivax B. Mature trophozoite of Plasmodium malariae . Macrogametocyte stage of Plasmodium ‘faleiparum D. Mature gametocyte stage of Plasmodium ovale Microbiologyltdentify microscopic morphology! Parasites3 ‘Chapter 10 | Photomicrographs and Color Plate Examination 541 Answers to Questions 16-20 16. A C.sinensis produces small ble-stained ova 7. 19. 20. 8 c B A approximately 25-35 yin length and 10-20 yin ‘width. Ova have 2 collar (shoulder) on both sides of the operculum and a knob at the end opposite the operculum. Fasciola, Paragenimus, and Fasciolopsis ll produce large, yellow-brown operculsted ova . westermani produces large, operculated ova measuring approximately 80-100 win length ‘and 50-70 lin width. They ate yellow-brown ‘and nonembryonated. Metagonimus and Opisthorchis ova are small ova resembling Clonorchis. Fasciola produces ova that are aso yellow-brown, operculated, and unembryonated The ova are larger than Paragonimus and lack the small shoulders adjacent to the operculum of Paragonimus ova, ‘This field shows long helical bacteria between red blood cals (RBCs) of normal size anc color. These spirochetes ae sometimes seen in the blood of patients suffering from the febrile septic phase of Infection with Borrelia or Leptospira spp, The former are more commonly encountered in differential exams, especially n patients infected with Borrelia recurrents and other species that cause relapsing fever. Borrelia burgdorfer, the causative agent of Lyme disease, is rarely seen in Wright's-sained! blood films and is usvally diagnosed by enzyme-linked immunosorbent assay (ELISA) and other serological methods This isa lage trophozoite with spiculated cytoplasm characteristic of Acanthamoebo, Cye Infections caused by this organism have been documented in contact lens wearers who do not propery disinfect lenses, Acanthamoeba spp. are large trophozoites measuring 25-50 1. They may also cause primary amoebic meningoencephalit', although they are isolated less often than Naegleria in the cerebrospinal uid (CSF) of patients with this disease ‘The infected REC demonstrates enlarged amoeba-ike cytoplasm and Schiifner's dots, hich are characteristic of P.vivar and ovale. The parasite is atthe ring-form tvophozoite stage.542 Chapter 10| Phowomicrographs and Color Plate Examination 21. 22, 23. 24, 25. Plate 21 is a modified acid-fast stain with malachite green counterstain of a stool specimen, 1,000x magnification. The oocysts seen in this field are approximately 5 1 in diameter. Which organism is present? A Loospora belli B. Ciyptoiporidium paroum €. Cyclospora spp. D. Sarcocystis spp. Microbiology Identify microscopic morphology! Parastes!2 Plate 22 is a Gram-stained CSF concentrated by centrifugation, 1,000x. Which organism is present? A. Neiseria meningitidis B. Staphylococcus aureus ©. Streptococcus pneumonia D. Listeria monocytogenes Microbiology/Identify microscopic morphology!CSFI2 Plate 25 is a urinary sediment viewed under 400x magnification using a brightfield microscope, ‘What is the object located in the center of the field? A. Schistosoma haematobium ovum B. Oval fat body ©. Gliter eel D. Fecal contaminant Body fluidilldentify microscopic morpholegy/Urine sedimentl2 Plate 24 is a urinary sediment viewed under 40x magnification using a brightfield microscope. ‘Which crystals are seen? A. Usic acid B. Calcium oxalace Ammonium magnesium phosphate D. Hippuric acid Body fluid Identify microscopic morphology/Urine sediment!2 Plate 25 is a urinary sediment viewed under 400x magnification using a brightfield microscope, Which crystals are seen? A. Uric acid B. Calcium oxalate . Ammonium magnesium phosphate D. Hippuric acid Body fluidilldensify microscopic morphology/Urine sediment!2 Answers to Questions 21-25 21. B Al ofthe organisms sted are coccidian parasites that cause dlarthea, especially in immunodeficient patients such as thase with AIDS. Cryptosporidium ppraduces the smallest oocysts (half the sze of, Cyclospora, which is the next smallest) and is visible in stools using either the acicfast or Immunofluorescent staining techniques. The ‘00cys5 ate round, about § yin diameter, and deep pink This field shows abundant gram-positive ciplocacci ‘with the lancet shape that is characteristic of S pneumoniae. Group 8 Streptecoccusis a common ‘cause of bacterial meningitis in infants Listeria may. cause bacterial meningitis in infants and elderly patients, while S.pneumonia is most often ‘encountered in middle-aged adults and older patients, Staphylococcus, Streptococcus, and Listeria Sep. are gram positive while Nevscena is gram negative, Listeria is a small coccobacilus or tod, Staphylococcus is rarely isolated frorn CSF and appears as small grapelike coc) B Oval far bodies are degenerated renal tubular epithelia that contain ahigh concentration cf neutral fat, laigely reabsorbed cholesteral droplets, These appear highly rfracile under brightield microscopy, and the fat globules produce a Maltese cross effect Under a polarizing microscope. Ova fat bodies occur in conditions associated wath increased urinary Ipoprote'n excretion such as the nephrotic syndeo Uric aie crystals are yellow to reddish-brown in ‘color and occur in acid or neutral urine, Common ‘ors include wretstones and ehombic plates (as seen here}, as well as thin needles and rosettes. Calcium oxalate crystal are usualy colaless cctahedrons. Ammonium magnesium phosphate cajstals are long, colorless siesided prsms, and hippuric acid crystals are colorless long, fat, hexagonal plates ‘Ammonium magnesium phosphate crystals (viple phosphate) occur in alkaline or neutral urine. They are long, colorless hexagonal prisms that often resemble a ‘coffin lt” they may also occur in a feathery form that resembles 2 fern leat. Triple phosohate crystals may form calcul inthe renal pelvis appearing on an xeray as an outline ofthe calyces and referred to as “stag-hom’ calcul.26, Plate 26 isa urinary sediment viewed under 400x magnification using a brightfield microscope. Which type of cast is present? A. Hyaline cast B. Broad cast ¢. Waxy cast D. Coarse granular east Body flidilldentify microscopic morphology/Urine sediment!2 27. Plate 27 shows a urinary sediment viewed under 40x magnification using brightlield microscopy. ‘This colorless crystal is presumptively identified as: ‘A. Calcium phosphate B. Acetaminophen ©. Cystine D. Hippuric acid Body fluidlIdentify microscopic morphology/Urine sediment!2 28, Plate 28 is a Wright’s-stained cytocentrifuge preparation of pleural fluid, 1,000x, What is the correct classification of the largest mononuclear cell located in the center of the plate? A. Histiocyte B. Macrophage C.Lymphoblast D. Mesothelial cell Body fluidilldentify microscopic morphology!Pleural fouidi2 28, Plate 29 is a Wright’s-stained smear of pleural fluid prepared by cytocentrifugation. ‘The largest cell in this field (see arrow) is identified as a: AA Signet ring macrophage B. Reactive mesothelial cell C. Foam cell D. Merastatic cell from the breast Body fluid/ldensify microscopic morphology/Pleural fuidi2 30, Plate 30 is from a Wright’s-stained peripheral blood film, 1,000x. Which of the following best describes the cells in this plate? A. Normal morphology B. Macrocytic red blood cells . Hypersegmented neutrophil present D. Reduced platelets Hematologylidentify microscopic marpholeg/RBCL2 ‘Chapter 10 | Photomicrographs and Color Plate Examination 543 Answers to Questions 26-30 26. D Coarse granular casts often form from degeneration 27. 28. 29. D A A of cellular casts. The finding of move than 2 care granular casts significant and helps to identity the kidney as the source of urnary protein and cells. Coarse and fine granular casts have the same significance as cellular casts and point to glomerular damage. Cystine crystals form in acid urine and appear as colorless uniform si-sided hexagonal plates in Urinary sediment Calcium phosphate crystals form inrneutal to alkaline une and appear as thin amorphous crystals resembling a sheat ofice or as flat needles that forma rosette, Acetaminophen crystals are cylinder shaped with round edges Hippuric acid crystals form long sbesided prisms in acid urine, Cystine crystals must be differentiated from uric acid on the bass of solubility, polarized microscopy, or biochemical testing, Cystine crystals {are ess anisotropic than uric acid. Cystine crystals are soluble in dilute hydrochloric acid (HCD, out Uric acids insoluble. Cystine causes 2 positive cyanide-nitroprusside test and uric acid does no. Mesothelal cells ae specialized epithelium that line the serous membranes, and they may be seen in small nurses in normal pleural, pericardial and ascites fluids. They ae often seen in increased numbers when there Ian inflammatory injury invohing the serous membranes. They ate large monenuclear a binucleate cells with an open chromatin patter and abundant agrenular cytoplasm. Mesothelil cells may transform into phagocytic ces and undergo morphological changes that cause them to resemble malignant call Macrophages ae frequently seen in seraus fuids. ‘They are ptesentin increased numbers in exudative conditions. Signet ring forms resul from compression ofthe nucleus agains the cell wall, usually caused by large vacuoles trat form after ohagocytos's of erythrocytes or fat ‘The £29, shape, and central pallor ofthe red cells in this plate are normal. The morpholagy of the ‘neutrophil i tyoical in appearance Platelets of normal size and shape are present. Ov average, th should be less than three platelets per ol immersion (1,000x) feld when thrombocytopenia present.544 Chapter 10| Phowomicrographs and Color Plate Examination 3. 32. 33. 34. 35. Plate 31 is a Wright's stained peripheral blood film, 1,000. What is the most appropriate classification of the red cell morphology seen in this field? A. Mictocytic, hypochromic B. Microcytie, normochromic €. Notmocytic, normochtomie D. Macrocytic, normochromic Hematolegylidentify microscopic morpholog/RBCI3 Plate 32 is a Wright’s-stained peripheral blood film, 1,000x. What is the most appropriate classification of the white blood cells (WBCs) present in this field? A. Reactive (atypical) lymphocytes B, Large lymphoblasts exhibiting L2 morphology . The M4 subtype of acute granulocytic leukemia D. Monocytes Hematologylldentfy microscopic morphology/WBCH3 Plate 33 is from a Wright's-stained peripheral blood film, 400x. Which of the following tests may be performed to enable an accurate diagnosis? A. Leukocyte alkaline phosphatase (LAP) stain B, Myeloid marker study by flow cytometry €. Myeloperoxidase stain D. Periodic acid—Schiff (PAS) stain Hematologylidentify microscopic morphology WBCI3 Plate 34 is from a Wright’sstained peripheral blood film, 400%. The cells seen are diagnostic of which condition? {A Incravascular hemolytic anemia B. Sickle cell disease ©. Myclofibrosis D. Exythroleukemia Hematologylldensify microscopic morphology RBCS. Plate 35 is from a Wright’s-stained peripheral blood film, 1,000x. Which description of the RBC morphology and places is correct ‘A. Mictocytic, hypochromic with marked poikilocytosis and increased platelets B, Macrocytic, hypochromic with marked anisocytosis and normal platelets . Normocytic, normochromic with mild poikilocytosis and increased platelets D. Microcytie, hypochromie, with mild anisocytosis and normal platelets Hematologylidentify microscopic morpholeg/RBC2 Answers to Questions 31-35 31, D Many ofthe RECS in this fle are lager than the 32. A 33.8 34.8 35.4 rucleus ofthe smalllymphacyte incicating that they are macrocytic Several of the RBCs are alipical in shape and are classified as ovalacytes. The region of central pallor of most of the cels is normal Mactocytic anemia (anemia with an increased mean cell volume MCV} is commonly seen in natients vith chronic ver disease, vitamin By, or folate deficiency, hypothyroidism, and alcoholism, These cells are phocytes characteristic of those found in viral infections such as infectious mononucleosis In these concitions, the WEC countis increased (usually 15-25 x 10%/p, and lymphocytes account for the majority of the WACs Reactive lymphocytes are larger than normal, The cytoplasm is increased in volume and may be vacuolated, and the edges of the cell are often scalloped and basophilic. The nuclear chromatin pattern is open and reticular This plate shows rrarked granulocytosis demonstrating cells at all stages of maturity and marked thrombocytosis. These characteristics suggest chronic myelogenous leukemia (CML), but they also occur in the leukemoid response, which is a severe granulocytosis in response to infection, inflammation, tissue damac malignancy. The LAP testis performed to distinguish the two coneitions. In CML, tne LAP score is markedly reduced, usually 10 or below. In the leukemoid response {and leukoeryth-oblastosis) the LAP score is elevated (elerence range 20-100) In addition to the LAP stain, cytogenetic evaluation isanather important diagnostic marker for CML, Ninety-five percent of patients with CML display the Philadelphia (Ph) chromosome in their ‘granulocytes, ‘This plate displays polychromasia, abundant target cells (leatocytes), and well-defined sickle cells (drepanocytes) characteristic of sickle cell disease Sickle ces are elongated with pointed ends, and the Hab is concentrated in the center of the cell They may also be encountered in afew other hemoglobinopathies, such as Hab SC disease, but ate rarely seen in patients with sickle cell tat, ‘These RBCs demonstrate extreme central pallor characteristic of ces that are microcytic and hypochromic, Target cells, ovalocytes, burt cell, ang cel fragments are present, On average, when ‘more than 20 platelets are seen per oilimmersion ‘eld the platelet count is elevated,36. 37. 38. 39. ‘Chapter 10 | Photomicrographs and Color Plate Examination Plate 36 is a Wright’s-stained peripheral blood film, 1,000x. The RBCs in this plate are characteristic of, A. Hemolytic anemia B. Myclofibrosis C. Higb C disease D. Sideroblastic anemia Hematolegyltdentify microscopic morphology RBCS 3 Plate 37 is a Wright’s-stained peripheral blood film, 1,000x. The cells seen in this plate are associated with: A. Lead poisoning B. Aplastic anemia C. Iron deficiency anemia D. Intravascular hemolysis Hematologylidentify microscopic morpholog/RBCI3: Plate 38 is from a Wright’s-stained peripheral blood film, 400x. Which of the following conditions is consistent with this RBC morphology? A. Exythroleukemia B. f Thalassemia major €. Folate deficiency anemia D. Autoimmune hemolytic anemia Hemaiologylidentify microscopic morpholog/RBCI3 Plate 39 is from a Wright's-stained smear of peripheral blood, 1,000x from a patient with a WBC count of 35 x 10°/L. The patient is 60 years old with firm, enlarged lymph nodes and hepatosplenomegaly. These same cells comprise 50% of the bone marrow WBCs and are positive for PAS and negative for myeloperoxidase and nonspecific esterase. What is the most likely diagnosis? A. Epstein—Barr virus infection B. Infectious mononucleosis ©. Chronic lymphocytic leukemia D. Waldenstrém's macroglobulinemia Hematology/Evaluate clinical and laboratory datal Leukemial3 36.8 37.8 38.8 39.¢ 545 Answers to Questions 36-39 ‘The peripheral slood in myelofloross is leukoerythroblastic and is characterized by teardiop cells (dactocytes), ovalocytes, nucleated RBC basophilic stipoling, poiklocytoss, eukocytes's, and (often) micromegakaryocytes, Hg® C disease produces normocytic or signtly microcytic anemia ‘with many target cells, Sidercblastic anemia produces bath microcytic, hypachromic RBCs, and ormocytic RBCs in the blood (dimorphic RBC morphology), Hemolytic anemias are usually normocytic, normochromic, or macrocytic with polychromasia, but morphology varies with the cause of hemolysis Several RBCs inthis plate show coarse basophilic stippling, Basophilcstippling results from unstable RNA within the cell and is associated with defects in Hb synthesis. This is most often associated with lead poisoning, hemoglobinopathies, myelofierosis, and megaloblastic anerias, This plate shows severe microcytic, hypochromic RBCS with numerous target cells and marsed anisocytos's A polychromatophilc normoblast is present. In addition, thalassemia is als associated ith poiklocytes, Howell-lolly Bodies, ovalocytes, and siderocytes. Folate deficiency produces a macrocytic anemia, and auto mmune hemalytic anemia is usualy normacytic, normachromic. The peripheral blood in erythroleukemia contains many nucleated RBC precursors demonstrating bizarre shapes. The WACS in this plate (with the exception of fone granulocyte) are small phocytes. Chronic Iympracytic leukemia is rare in patients under ‘the age of 30. The peripheral blood demonstrates a precominance of small lymphocytes, usually 20-200 x 10%/L, which comprise at least 40% of the bone marrow WECs. Flow cytometry indicates these cells to be B cells in approximately 95% of ‘cases, The bone marrow in Waldenstram's macroglobulinemia is infkrated by plasmacytoid lympnocytes, slasma cells, and mast cells, a5 well as small lympnocytes; however, a severe peripheral lympnocytosis snot seen. lymphadenopathy ‘and hepatosplenomegaly occur in Infectious mononucleosis. The ymphocyte count is usually 15-25 x 10%/, but the cells are atypical, being characterized by reactive features. The bone marrow is usually hyperplastic but not infltrated by small lymphocytes546 Chapter 10| Phovomicrographs and Color Plate Examination 40. a. 42, Plate 40 is from a Wright's-stained peripheral blood film, 400x. The RBC morphology is most consistent with which of the following ancmias? A. Folate deficiency B. Iron deficiency €. Hemolytic D. Sideroblastie Hematolegylidentify microscopic morpholeg/RBCI3 Me. Vacini, an Italian immigrant, has been hospitalized with tachycardia, a rapidly. decreasing hematocrit, and blood in his urine. ‘Twenty-four hours prior to admission, he had taken his first dose of a sulfonamide prescribed for a urinary tract infection. Plate 41 is from a ‘Wright's-stained smear of his peripheral blood, 1,000x. Which laboratory test would be helpful in establishing a diagnosis of Mr. Vacini's hematologic problem? A. Heinz body preparation B, Hgb H preparation © Iron stain D. New methylene blue stain Hematologylidentify microscopic morpholog/RBCI3 a. Plate 42 is from a Wright’s-stained smear of peripheral blood, 1,000x. The bone marrow aspirate of this patient demonstrated an, abundance of cells with this morphology. Which of the following conditions is most likely to be associated with this sample? A. Sézary syndrome B, Hodgkin's disease . Burkic’s lymphoma D. Multiple mycloma Hematologylidentify microscopic morpholog/WBCI3. Plate 43 is from a Wright's-stained peripheral blood film, 1,000x. The WBC appearing in this plate is most likely a: A. Mycloblast B. Promyelocyte ©. Myelocyte D. Monoblast Hematologylidentify microscopic morphology! WBCA2 A 42. 43.4 Answers to Questions 40-43 40. D The REC morphology of this field's characterized by the presence of both microcytic,hypochromic, and normocytic, normachromic cells. Ths dimorphic appearance is a characterstic of sideroblastic anemias. Folate deficiency causes a megaloblastic anemia causing 2 macrocytic, normochromic appearance. ron deficiency is associated with a rmicrocytic, hypochromic RBC morphology. Hemalysic anemias are often normocytic, normochromic, The RBC morphology seen inthis plate shows both anisocytosis and poikilocytosis with prominent schistocytes that indicate 2 hemolytic anemia, The patient’ ethnic background, cliical findings, and sulfonamide therapy point to a hemolytic episode ‘of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency as the cause, Ts can be substantiated byan assay of exythrocyte G-6-PD, The enzyme deficiency results in oxidative damage to RBCS ‘causing formation of Heinz bodies (prec pitated High), Heinz bodies are demonstrated by staining with crystal violet and will be pitted from the RBCs by the spleen, resulting in RAC fragments sometimes called bite or helmet cals The cellin the center ofthe plate isa plasma cel Such cells have a dense, eccentricnuckeus tats sutrounded by a clear perinuclear area that represents the Golgi apparatus. The cytoplasm is basophilic and more abundart than is seen in small Iymehocytes. Plasma cells are nat normally seen in peripheral blood. They may be found. cases of viral and chronic infections and connective Ussue diseases, as well asin myeloma and other plasma cell dyscrasias. The RBCS in this plate demonstrate rouleaux which isa characteristic seen in muliple myeloma, The peripheral blocd in Hodgkin's disease Is characterized by neutrophilia and lymphopenia Burkit’s mmphoma produces very large, intensely basophilic hmmphoblasts(L3 morphology). Abnormal lymehocytes appearing in peripheral elood in Sézary syndrome ae large with a convoluted nucleus of fine chromatin and alrast no cytoplasm, Blasts are usually 15-20 yin dameter with alarge nucleus containing fine chromatin. The cytoplasm is Usually agranular and basophil. Lymphoblasts are differentiated from myoloblasts by cytochemical staining and flow cyiomeny. Ths blast contains Uniform, unclumped chromatin, nuttiple nucleo, the absence of azurophilic granules, and is from a patient with acute myelogenous leukemia, FAB M0 Lymphoblasts often display regular clumping of the chromatin and azurophilic granules. They usually lack prominent nucleo44, 4s. 47. Plate 44 is a Wright’s-stained peripheral blood film, 1,000x. The white blood cells inthis field are negative for peroxidase, chloroacetate esterase, and Sudan B. The cells are positive for terminal deoxynucleotidyl transferase (Ts) and PAS. On the basis of these findings, what is the most appropriate classification of these cells? A. Lymphoblasts with L1 morphology B. Lymphoblasts with L2 morphology €. Lymphoblasts with L3 morphology D. Chronic lymphocytic leukemia cells Hematologylidentify microscopic morphology WBCI3 Plate 45 is from a Weight’s-stained peripheral blood film, 1,000x. Sixty percent of the WBCs ate positive for naphthol AS-D chloroacetate esterase (specific esterase), and 70% are positive for c-naphthy! acetate esterase (nonspecific esterase). ‘The WBCs in this plate are characteristic of which FAB subtype of acute nonlymphocytic leukemia? AMI B.M2 M3 D.Ma Hematologyldentify microscopic morphology WBCIS. Plate 46 is from a Wright’sstained peripheral blood film, 1,000x. The WBCs shown in this field are classified as: A Blasts B. Prolymphocytes C. Plasma cells D. Myclocytes Hematologylldentfy microscopic morphology/WBCI3 Plate 47A shows cells from the same sample as plate 46 after peroxidase staining, 1000x. Plate 47B is a normal peroxidase-stained peripheral blood film, 1,000x, which is used as a control. ‘The blast cell shown in plate 47A is B. Weakly peroxidase positive €. Peroxidase negative D. Invalid because of an improper control reaction Hematologylidentify microscopic morphology/Special sainsl3 Chapter 10 | Photomicrograph and Color Plate Examination 547 Answers to Questions 44-47 44, A The cytochemistry 45. 47. A A se coll is characteristic of Ilymehoolasts, and they exhibit marchology that is characteristic of the LI sutype of acute bmmphocytic leukemia. LI cell have scarce cytoplasm thats moderately basoptilc. The cells ate small ang Uniform in size and shape. They either lack nucleolus or have one or wo small nucleo. L2 cells are large and irregular in size and often contain one ormore prominent nucleok,L3 cells are large and Uniform in size with deeply blue cytoplasm, They have muiple prominent nucleoli ‘These WECS ate large blasts containing a convoluted nucleus, lrge nucleo lacy nuclear chrom: abundant cytoplasm. These are characteristics of monoblasts, MT is myeloblstic leukemia without maturation. M2 is myeloblastic keukemia with maturation. M2 is promyelocytic leukemia, and MA is myelomonecytic leukemia, Acute myelomonocytic leukemia comprises 2034-209 of acute myelogenous leukemias in adults and usually occurs in persons ‘over 50 years old. More than 3086 of nucleated cells in the bone martow are blasts and 2086 or more af the nucleated bore marrow calls are monoblhsts ot monocytes. The nucleated cel’ shown in this hotomicrograp” havea large nucleus with open, unclumped chromatin and scant agranular blue cytoplasm. Chromatin is ticular and nucleal are prominent. Although nuclear folding is present, Auer rods are not seen and, therefore, the origin ofthe blasts must bee determined by cytochemical and immunologic characteristics. ‘The conto slide shows peroxidase staining of the granules in three mature neuttophils and indicates thatthe stain is functioning er he cytoplasm ofthe blast in plate 47A i sitive for peroxidase, indicating that itis a myeloblast When at least 3% of blasts stain positve, the testis considered positive, Acute myeloblastc leukemia (AML with minimal differentiation, MO, isn ‘with peroxidase stain. M1 through Mé classes of AML are peroxidase positive, MS may be weakly positive, and myeloblasts in M6 are positive. | yrph hairy cells, erythroid cells, megakaryocytes, and platelets are negative. Reactions for Sudan Black B parallelthose of peroxidase548 Chapter 10| Photomicrographs and 48. 49. 50, st. 52. Plate 48 is from a Wright's-stained peripheral blood film, 1,000x. The WBC shown in the center of the field (see arrow) is classified as a: A Bhst B. Promyelocyte ©. Myelocyte D. Prolymphocyte Hematologyldentify microscopic morphology WBCs2 Plate 49 is a Wright’s-stained peripheral blood film, 1,000x. What is the most appropriate classification of the WBCs seen in this field? ‘A. Lymphoblasts B, Myeloblasts €. Promyelocytes D. Prolymphocytes Hematologylidentify microscopic morphology WBCI3 Plate 50 is a Wright’s-stained peripheral blood film, 1,000x. Which description best characterizes the morphology of the neutrophil shown in this plate? A. Normal morphology B, Dahle bodies €. Toxic granulation D. Hypersegmentation Hematologylidentify microscopic morphology/WBCA2 Plate 51 shows a urinary sediment under 400x ‘magnification stained with Sternheimer-Malbin stain, What is the large object to the right of the center of this field? A. Squamous epithelial cell B. Artifact €. Renal epithelial cell D. Transitional epithelial cell Body fluidlldentify microscopic morphology/Urine sedimentl2 Plate 52 shows a urinary sediment under 400x magnification stained with Sternheimer-Malbin stain, What is the large cell to the right of the center of the field? A.WBC B. Transitional epichelial cell €. Renal epithelial cell D. Squamous epithelial cell Body fluidelldentify microscopic morphology/Urine sediment!2 jor Plate Examination Answers to Questions 48-52 48. B Promyelocytes are often larger 49.8 50. C st. 32. 1an myoblasts wundant than in the and the cytoplasm is mor rmyeloblast. The nuclear chromatin is open but Usually is slightly conceensed, and one or more nucleoli may be present. The cytoplasm is elue and contains large azurophilc (primary) granules, but no secondary granules In contrast, the myelocyte has a round nucleus that is smaller, the chromatin is more condensed, and nuclei are absent. The cytoplasm of the myelocyte is urple, an granules predominate, ‘The nucleated cells shown in this field are blasts. The large blast seen in the corner of the plate contains a prominent Auer fod, Auer rods are linear pr of azurophil granules and are seen myelocytic leukernia. Auer rods are usually rmyeloblasts or promyelocytes and are seen in MM, M2, and MB subtypes of AML secondaty This neutrophil displays an abundance of large purple azurophilic aranules characteristic of toxic ‘granulation The granules co acid hysrolyases that result in increase Toxie granulation i fo tio inflammatory consitions and iseften present in band cells and metamyelocytes, which are usually Increased in these conaltions. Dahle bodies and ‘vacuolated neutrophils may be seen in association with toxic granulation in peroxidase and basophil und in severe i Squamous epithelial cells ate large cuboidal cells approximately 50-70 pin diameter. They have a small condensed nucleus about the size of an RBC, and stain reddish pink with Sternheimer-Malbin stain, ranstional epithelial cll tain 2 pale blue, and have far less abundant cytoplasm. Renal epi calls have a purgle-blue nucleus, and orange-purple cytoplasm with a nuclearcy approximately Renal epithelial cells are usually polyhedral, teardrop, cor columnar in shape with a dist appearance Staining with Sternheimer-Mabin is dependent on the pH of the sample. Renal cells stain ‘with 2 dark purple-blue or redaish purple nucleus and lighter purple or orange-purole cytoplasm. In contrast, transitional cells are about the same size but stain witha blue nucleus and pale blue sytoplasm, There is a small hyaline cast in the upper left comer ofthe field.53. 54, 55. 56. 57. ‘Chapter 10 | Photomicrographs and Color Plate Examination Plate 53 shows a urinary sediment under 400x magnification stained with Sternheimer-Malbin stain, What is the large cel in the lower right of the field? AWC B. Transitional epithelial ell €. Renal epithelial eell D. Squamous epithelial cell Body fluidilldentify microscopic morphology/Urine sediment!2 53.8 Plate 54 shows a urinary sediment under 400x cena ‘magnification stained with Sternheimer-Malbin stain, What is the large object to the right of the center of the field? Cast B, Mucus ©. Artifact D. Hair Body fluidilldensify microscopic morphology/Urine sediment!2 55.8 56. 8 Plate 55 is a Wright’s-stained cytocentrifuge preparation of pleural fluid, 1,000x, What is the large cell near the center of the field? A. Macrophage B. Mesohelial cell © Blast D. Plasma cell, Body fluidilldentify microscopic morphology!Pleural Pouidi2 Plate 56 is a Papanicolaou-stained seminal uid, 1,000x magnification. What isthe round cell near the center of the field? A.WBC 8B. Primary spermatocyte ©. Histiogyce D. Spermatid Body fluid/Identify microscopic morphology/Seminal fidi2 Plate 57 is a Wright’s-stained bronchioalveolar lavage (BAL) fluid, 1,000x magnification. ‘The cellularity in this field is suggestive of which condition? A. Bacterial pneumonia B. Rheumatoid arthritis €. Lymphoma or leukemia D. Smal cell carcinoma Body fluidilldentify microscopic morphology/BAL Pouidi2 57. C 549 Answers to Questions 53-57 Transitional epithelial cells are 20-30 win alareser, ‘and often swell in urine of low specie gravity, causing a lower nuclearcytoplasm ratio than seen in renal epithelium, Tnose originating rom the neck of the urinary bladder or the pelvis ofthe kidney often have a sawtooth (caudate) shape, but otherwise they are oval. Transitional cels stan pale blue with Sterheimer-Malbin stain, This cast is mostly hyaline, although it contains some granular material An RBC fs superimposed on the Upper part ofthe cast. The field also contains R&Cs, a Tew fresh WBC, bacteria, and possibly yeast. Mesothelal cells can transform into phagocytic cells ‘and often resemble macrophages in appearance. This cell has slightly granular cytoplasm, stippled nuclear chromatin and a rough cytoplasmic membrane characteristic of reactive mesothelial cells Immature sperm cells may be seen in seminal ui, ‘and should be quantified separately from the sperm count. primary spermatocyte isa large diploic cell with a large nucleus containing uncondensed chromatin. divides to form secondary spermatocytes, which ate haploid. [hey are smaller vith 2 higher nucleareytoplasmic ratio and condensed chromatin, Spetmatids are immature sperm cells that display 3 highly condensed nucleus (often multiple nuclei) and often show the beginning fatal WBCs may aso occur in seminal uid and may be difficult te distinguish from secondary spermatocytes, “ne nucleus shows distinct constrictions bridging the lobes. ‘The dominant cals in this field are blasts suggestive ofa leukemia o bmphoma that has infikrated the pleura. The cells are large with an immature nucleus and multiple prominent nucleoli Bacterial infections are associated with neutrophilic infiltration (called a parapneumonic effusion). A causes a mixed-cel paatzemn containing many large macrophages, PMNS, plasma cll, and atyoical lymahocytes. Smal cell carcinoma often produces exudates in which the malignant cells appear in rows with thelr nucle almost uchina550 Chapter 10| Photomicrographs and 58, Plate 58 is a 1,000x ficld of a FISH test for BCRIABL using a dual fusion probe, consisting of a Spectrum Green-labeled probe to the BCR 22 411.2 locus, and a Spectrum Orange-labeled probe to ABL 9434 and counterstained with DAPI. The cells are in interphase. The cells in this field are best described as: A. BCRIABL positive B. BCRIABL negative €. BCR/ABL positive with an atypical pattern D. Inconclusive Molecular/Evaluate microscopic morphology!3 59, Plate 59 is a 1,000x field of a FISH test for BCRIABL using a dual fusion probe, consisting of a Spectrum Green-labeled probe to the BCR 22 411.2 locus, and a Spectrum Orange-labeled probe to ABL 9q34 and counterstained with DAPI. he cells are in interphase. he cells in this field are best described as: A. BCRIABL positive B. BCRIABL negative €. BCRIABL positive with an atypical pattern D. Inconclusive Molecular{Evaluate microscopic morphology(3 60, Plate 60 is a Papanicolaow-stained seminal fluid, 1,000x magnification. What are the nuclear defects present in the cells labeled 1, 2, and 3? ‘A. 1: Microcephalic 2: Macrocephalic: 3: Normal B.1:Acrosomal 2: Pyriform head 3: Tapered deficiency head G1: Tapered head 2: Macrocephalic 3: Normal D.1: Amorphous 2: Normal 3: Tapered head head Seminal Fluid/Evaluate microscopic morphology/3 BIBLIOGRAPHY 1, Gutcia LS. Diagnostic Medical Parasitology. 5th edition, 200) ASM Press, Washington, DC. 2, Harmening D. Clinial Hematology and Funds Hemostais. Sth edition, 2009. F-A. Davis, Philadelphia 3. Larone DH. Medically Important Fung A Guide to Identification ‘Ab edtion, 2002, ASM Press, Washington, DC. jor Plate Examination Answers to Questions 58-60 58. A Three ofthe four cals show yellow fusion spots, Indicating tnat both dyes are bound tothe locus. ‘This pattern of tivo fusion spots indicative of two hybrid genes with a single red and green spot indicative of normal chromosomes 9 and 12s seen In about 90% of BCR/ABLs. About 10% demonstrate other patterns owing ta deletion (I red, 1 green, 1 yellow or 1 green, 2 yellow) or ploidy (1 red, 1 green, 3 yellow, cr 1 red, 2 green, 3 yellow) or Unbalanced translocation (1 ed, 2 green, 1 yellow 59. B The fivecalls in this ield are normal Each expresses two green and two red hybridization spots. kis normal fr probes to demonstrate a dumbbell shape because binding tothe locus is nat always uniform. A positive cell usually demonstrates one green, one red, and two yellow spots. The yellow is produce the adjacent binding of the orange and green probes This represents a balanced translocation between chromosomes 22q and 9a, A cutoff of > 2% cells with double fusion spots is considered postive. 60. B Spermatozoons should be evaluated based upon a strc riterion, In this photomicrograph, sp 1 demonstrates an almost complete absence of the anterior portion ofthe head, the acrosome, which should account for at least 40% ofthe head area, The head of spermatezoon 2 is teardrop shaped: this is referred 1038 a py width ratio of spermatazoon 3s excessive (>175), whichis refered to as a tapered head. When a strict criterion is used to grade morphology, thereis a significantly higher probabilty of male inferlty when normal forms comprise les than 4%6 of te spermatozoons smatoz00n m head. The head length to 4, McPherson RA and Pincous MR. Henry Clinical Diggove sind Management by Laboratory Methods 220d edition, 2011 WB. Saundets, Philadelphia,COLOR PLATE SECTION 123 45 67 8 Plate 1 Plate 2 a oe © a= === rises ries ones rf 123 45 67 8 9 10 : fs fe ahees S55 E ® . [s ~ = 5 Plate 6 Plate 7COLOR PLATE SECTION i234 5 6 % 8 3 40 a - o a a-.lhl= —Ce@e08- e2e- ~ - Plate 8 Plate 9 Plate 10 Plate 11 Plate 12 Plate 13COLOR PLATE SECTION pe] Plate 14 Plate 15 Plate 16 Plate 17 Plate 19 Plate 20 Plate 21COLOR PLATE SECTION mete ast Plate 22 Plate 23 : Vee aeWw\ my : So Ys ty by Plate 24 Plate 25 Plate 26 Plate 27 Plate 28 Plate 29COLOR PLATE SECTION wv - *ov OOF 6,53 on . ° e a0" gio 40 a® ye f , \ & ef Plate 34 Plate 36 Plate 37COLOR PLATE SECTION 5 Seatac (Ro aes tw ‘ee , “ae on plate a1 OOo “o 06 % é 005 0 2 O 2086 oe @ ° Oo 0 oe We 8 i of 0 S ° ; @o%o 05 Or. 0 . C9ecs Plate 42 Plate 43 ce nas en" Plate 44 Plate 45COLOR PLATE SECTIONCOLOR PLATE SECTION Plate 53, Plate 54 a ee 5 . os : * ’ Plate 56 Plate 58 Plate 59 Plate 60