WBC Morphology and Cases

Dr. Gilberts Lab

OBJECTIVES:
Learn how to identify the types of white
blood cells normally present in a
differential count.
Recognize abnormalities in white blood
cell numbers and what they imply.
Identify changes in white blood cell
number and morphology with infection and
leukemia.

HOW TO REVIEW A BLOOD SMEAR

First, look under low power to find the area where the
cells can be best evaluated, i.e., towards the feathered
edge of the smear. Then, look at the slide under medium
power to estimate the leukocyte count and to determine
whether the white blood cells are of one cell type
(abnormal) or whether there are several types of white
blood cells present (normal). As you gain experience in
looking at blood smears, the medium power is good for
picking up immature cells (blasts) when there are only a
few of these present.
Next, examine the cells under high power (40X
objectives and 100X oil objective). Be sure to wipe the oil
from your objective and the slide; otherwise, you will get
the oil on your other objectives. Examine the red blood
cells, white blood cells, and platelets systematically. In
this laboratory session, we are mainly concerned with
white blood cell disorders.

CASE 1
Description:
These normal blood smears show normal red
blood cells, white blood cells, and platelets.

Slide 1.1
This normal peripheral smear demonstrates a segmented
neutrophil and a band neutrophil.

Slide 1.2
This normal peripheral smear demonstrates a segmented
neutrophil and a lymphocyte.

Slide 1.3
This normal peripheral smear demonstrates a monocyte.

Slide 1.4
This normal peripheral smear demonstrates an eosinophil
and a lymphocyte.

Slide 1.5
This normal peripheral smear demonstrates a
basophil, a segmented neutrophil, and a lymphocyte.

Identify the following:

Polymorphonuclear leukocytes (PMN's, neutrophils)

Lymphocytes
Monocytes
Eosinophils
Basophils (may be difficult to find in this smear)
A manual white blood cell differential count consists of looking at
100 white cells and enumerating them in the above categories.
An automated white blood cell differential count is done by a
laboratory instrument that analyzes thousands of white blood
cells and categorizes them as a percentage of granulocytes,
lymphocytes, and monocytes.

CASE 2
History:
This 16 year old male came to the emergency
room complaining of severe abdominal pain in
the right lower quandrant. He had a fever of
101 F. On physical examination, he had a
rigid, board-like abdomen and rebound
tenderness in the right lower quandrant. There
were no other abnormalities.

Slide 2.1
This peripheral smear demonstrates increased
segmented and band neutrophils.

Laboratory studies:
Urinalysis was within normal limits. A CBC
showed Hgb 14.8 g/dl, WBC 20 X 109/L, and
platelet count 240 X 109/L.

Questions:
1. What is the predominant white blood cell
present?
2. What is the name for this type of
leukocyte reaction?
3. What do you think is the diagnosis in this
case?

CASE 2: Neutrophilic Leukemoid

Reaction
1. What is the predominant white blood cell present? The
majority of white blood cells present here are
polymorphonuclear leukocytes, and notice that, at
low power, the white blood cell count is higher than
in a normal smear. In addition to the PMN's, a small
but increased number of band forms are seen. Other
cells present are lymphocytes and monocytes, but
these are not increased. However, the platelets are
moderately increased in number.
2. What is the name for this type of leukocyte reaction?
The name of this reaction is known as a neutrophilic
leukemoid reaction.
3. What do you think is the diagnosis in this case? The
diagnosis in this case is acute appendicitis (most,
but not all, cases of acute appendicitis are
accompanied by peripheral neutrophilia).

CASE 3
History:
This 15 year old female was sent home from
summer camp because of weakness,
lassitude, and sore throat. As her family
physician, you found that on physical
examination she had an inflamed pharynx,
enlarged tonsils, several enlarged and slightly
tender lymph nodes in the neck, a palpable
spleen, and a tender palpable liver edge.

Slide 3.1
This peripheral smear demonstrates atypical lymphocytes.

Laboratory studies:
CBC showed Hgb 14.9 g/dl, WBC 12.5 X
109/L, and platelet count 282 X 109/L

Questions:
1. What is the predominant white blood cell
type?
2. What is your diagnosis in this case?
3. What is the differential diagnosis?
4. What other laboratory test may be
helpful in arriving at a specific diagnosis?

CASE 3: Infectious Mononucleosis

with Atypical Lymphocytosis
1. What is the predominant white blood cell type? The
predominant cell is a lymphocyte. There is an
absolute lymphocytosis with many atypical
lymphocytes (large lymphs with abundant light to
deep blue cytoplasm, round to ovoid nuclei with
occasional indentation, and many nucleoli).
2. What is your diagnosis in this case? The diagnosis is
infectious mononucleosis.
3. What is the differential diagnosis? The differential
diagnosis includes various viral infections including
hepatitis and cytomegalovirus. This process should
not be confused with leukemia.
4. What other laboratory test may be helpful in arriving at a
specific diagnosis? A serologic test for infectious
mononucleosis would confirm the diagnosis in most
cases.

CASE 4
History:
This 30 year old male had noticed progressive
weakness for one month. On physical
examination, a few small lymph nodes were
palpable in both axillae, and the tip of the
spleen was palpable. There was also sternal
tenderness present.

Auer rod

Slide 4.1
This peripheral smear demonstrates myeloblasts with Auer rods.

Laboratory studies:
CBC showed Hgb 10.2 g/dl, WBC 67 X
109/L, and platelet count 36 X 109/L

Questions:
1. What is the predominant white blood cell
type in this case?
2. Do you see any intracytoplasmic
markers which are diagnostic in this
case?
3. What is your diagnosis?

CASE 4: Acute Myelogenous

Leukemia
1. What is the predominant white blood cell type in this
case? Most of the WBC's in this peripheral smear are
myeloblasts. Except for occasional mature
neutrophils, intervening stages of maturing
neutrophils are not seen. Some nucleated red blood
cells are also present. Platelets are reduced in
number and some large forms are seen.
2. Do you see any intracytoplasmic markers which are
diagnostic in this case? A diagnostic marker is the
presence of slender red, needle- like bodies in the
cytoplasm called Auer rods.
3. What is your diagnosis? The diagnosis is acute
myeloblastic leukemia (AML). Most patients with
acute leukemia have a markedly decreased platelet
count. A peroxidase or Sudan black stain will
identify the blasts as being of granulocytic series.

CASE 5
History:
This 65 year old male was in good health
except for mild hypertension. At his last
check-up, a CBC showed a markedly elevated
white blood cell count and physical
examination revealed several slightly
enlarged lymph nodes in the neck and the
axillae, and the spleen was palpable.

Slide 5.1
This peripheral smear demonstrates increased numbers of
small mature lymphocytes.

Laboratory studies:
CBC showed Hgb 12.8 g/dl, WBC 130 X
109/L, and platelet count 330 X 109/L

Questions:
1. What is the predominant white blood cell
type present?
2. What is the differential diagnosis?

CASE 5: Chronic Lymphocytic

Leukemia
1. What is the predominant white blood cell type
present? Most of the white blood cells are
small to medium-sized lymphocytes. There
are also many smudged lymphocytes
present. In addition, one sees some larger
lymphocytes with abundant cytoplasm and
a prominent nucleolus which are
prolymphocytes.
2. What is the differential diagnosis? The only
real diagnostic consideration in this case is
chronic lymphocytic leukemia (CLL).

CASE 6
History:
This 52 year old male had gradually
increasing fatigue together with discomfort in
the left upper quandrant. Physical
examination revealed an easily palpable
spleen and liver edge. A few slightly enlarged
lymph nodes were palpable in the neck.

Slide 6.1
This peripheral smear demonstrates increased numbers of
granulocytes, mostly mature forms, as well as increased platelets.

Slide 6.2
This peripheral smear demonstrates increased numbers of
granulocytes with mature and immature forms.

Laboratory studies:
CBC shows Hgb 13.2 g/dl, WBC 46 X 109/L,
and platelet count 754X 109/L

Questions:
1. What type of white blood cells are
present?
2. What is the differential diagnosis and
how would you resolve it?
3. What is the diagnosis in this case?

CASE 6: Chronic Myelogenous

Leukemia
1. What type of white blood cells are present? The white blood cell
count is moderately elevated, with a wide spectrum of
granulocytes at various stages of maturation (rare blasts and
promyelocytes, myelocytes, metamyelocytes, bands, and
PMN's). In addition, there is an increase in eosinophils and
basophils (which would help to rule out a leukemoid reaction
as a cause for the WBC elevation). Platelets are moderately
increased in number and some large forms are seen.
2. What is the differential diagnosis and how would you resolve it? The
differential diagnosis is leukemoid reaction versus chronic
granulocytic leukemia. The increase in eosinophils and
basophils suggests leukemia. A leukocyte alkaline
phosphatase (LAP) score would also help (high with leukemoid
reaction, low with myelogenous leukemia). A Philadelphia
chromosome identified by cytogenetic studies on an bone
marrow aspirate would help to confirm CML.
3. What is the diagnosis in this case? The diagnosis is chronic
granulocytic (myelogenous) leukemia (CML).

CASE 7
History:
A 5 year old boy has been too tired to play
with his friends for two months. His mother is
also worried that, whenever he falls or bumps
into anything, a big bruise forms. For the past
two days he has had a high fever.

Slide 7.1
This peripheral smear demonstrates increased
numbers of immature lymphocytes.

Laboratory studies:
CBC shows Hgb 9.8, Hct 28.2, MCV 95, platelet
count 74,000, and WBC count 2,300 with
differential count 23 segs, 15 bands, 12 monos,
44 lymphs, 5 eos, and 1 baso. A bone marrow
biopsy shows replacement by primitive cells that
have large nuclei with delicate chromatin and
indistinct nucleoli. There is scanty cytoplasm
with no granules and no Auer rods. These cells
mark for CD10 (CALLA) antigen.

Questions:
1. What type of white blood cells are
present?
2. What is the most likely diagnosis?
3. What is the most likely outcome of this
child's disease with standard therapy?
4. What other test could be helpful in
distinguishing the nature of the cells in
this case?

CASE 7: Acute Lymphocytic

Leukemia
1. What type of white blood cells are present? The white
blood cells present are predominantly
lymphoblasts.
2. What is the most likely diagnosis? The most likely
diagnosis is acute lymphocytic leukemia (ALL).
3. What is the most likely outcome of this child's disease
with standard therapy? The most likely outcome of
this child's disease with standard therapy is good--a
>90% chance for complete remission following
chemotherapy.
4. What other test could be helpful in distinguishing the
nature of the cells in this case? A TDT (terminal
deoxyribonucleotidyl transferase) test is positive in
cases of lymphoid leukemias.