Good morning Curofians. Posted above are 4 pictures of a Neutrophilic condition on peripheral blood smear, I recently came across in the laboratory. A. Identify the abnormality observed in the neutrophil. B. What does it signify? C. Conditions we come across with such abnormality? Please note : Only orderly, comprehensive and complete answers will be given weightage for selection. Thanks. Best regards. [ Credits : Dr. Kazi Wajid Husain,. MD)

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Respected Dr. Yashaswini thank you for your doubts. Now let me give you brief findings of this case : 27 year old male patient, septicemic, bed ridden. His CBC revealed : ..Hb : 10.7 gm%, ..WBC counts : 17,000 cells/cumm, ..Platelet counts : 1.2 lakh/cumm, ..MCH- 30.0 Pg, ..MCV- 102 fl, ..RDW- 16.6 % ..DC : N - 91% [Seg N : 74%, Bands : 14%, Meta-myelocytes : 03%] , L- 06%, E-01%, M-02%], Peripheral smear : RBC- Mild anisopoikilocytosis, Normocytes, some macrocytes and few microcytes seen. Normochromia, Rare schistiocyte seen, No hemoparasites seen. WBC- Counts increased with Neutrophils predominantly, Mild shift to left. Toxic vacuolations+ Occasional Hypersegmented neutrophils seen, No abnormal cells seen. Platelets- Mildly deceased on smear. Impression : 1. Dimorphic Blood picture, Mild degree, 2. Neutrophilic leukocytosis with mild shift to left and toxic vacuolations. 3. Mild thrombocytopenia. ........ Revered madam, kindly refer the picture above to see the red dots above those some MACRO-OVALOCYTES AND macrocytic cells in comparison to other red cells. Thank you madam.

Madam, Now coming to your differential diagnosis query: What the CBC & PBF says in MDS? Significant changes are found in blood counts and morphology in patients with MDS. Peripheral blood count may show a single cytopenia (anemia, thrombocytopenia, or neutropenia) in early phase or bicytopenia (2 deficient cell lines) or pancytopenia (3 deficient cell lines) in later stages. Anemia varies in degree from mild to severe. It is usually macrocytic (mean cell volume of >100 fL) with red blood cells (RBCs) that are oval-shaped (macro-ovalocytes). It is usually dimorphic (2 or more populations), with a normal or a hypochromic microcytic population (RARS) coexisting with the macrocytes. Punctate basophilia is observed in RBCs. NEUTROPENIA may vary from mild to severe. Morphologic abnormalities are often observed in the granulocytes. These can include bilobed or unsegmented nuclei (pseudoPelger-Huet abnormality) or hypersegmentation on the nuclei (6-7 lobes) similar to megaloblastic diseases. GRANULATION ABNORMALITIES vary from an absence of granules to abnormal distribution inside the cytoplasm (Dohle bodies). Platelet counts are decreased. Abnormalities such as GIANT HYPOGRANULAR PLATELETS & MEGAKARYOCYTE FRAGMENTS are present. [Reference : http://emedicine.medscape.com/article/207347-workup#c7] Thrombocytopenia in our case is purely due to sepsis. There is neutrophilic leukocytosis with shift to left and TOXIC VACUOLATIONS AND NOT GRANULATIONS ARE NOTED to support this. And its just a mild degree of nutritional anemia due to B12 deficiency. Hope this clears up your doubt madam. Thank you very much.

Respected sirs and madams, SUGGESTIVE KEY : A. Identify the abnormality observed in the neutrophil. Neutrophils in the images posted exhibits TOXIC VACUOLATIONS in Hyper segmented neutrophils [Fig 1&4] ,segmented [Fig 2] and a possible Band cell [Fig 3]. B. What does it signify? Toxic vacuolation signifies reactive changes and is not pathological since the body is responding normally in an effort to rid itself of infection caused by bacteria.The presence of the vacuoles indicates increased spontaneous phagocytic activity of neutrophils in response to septicemia. C. Conditions we come across with such abnormality? Vacuoles are frequently seen in conditions such as infection or burns. Presence of vacuolated neutrophils in blood smears of patients suffering from infection appears to be associated with massive bacterial growth and constitutes a very early symptom of rapidly life-threatening septicaemia. Thank you one and all. Comments are welcome. Best regards.

@Dr. Monideepa Chattopadhyay madam, The significance of toxic vacuolation is summarized above. Thanks.
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fig 1. shows a hypersegmented neutrophil lobes are more than 5, azurophilic granules, sex chromatin, shift to right, bad prognosis occurs in megaloblastic anaemia, myelodysplastic syndromes, liver diseases, drugs, infections. fig 2. band form or immature neutrophil , shift to left is good prognosis.

Thank you very much revered sir for your valuable interaction and participation.
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Thanks for the images sir... Peripheral blood smear shows- Erythrocytes- normocytic normochromic blood picture with mild variation in the shape of RBC'S WBC'S- Showing hypogranular and vacuolated cytoplasm with hypersegmented, hypolobed nuclei with abnormal chromatin bridging. Single pseudo Pelger Huet cell seen. Platelets- Morphology founds to be normal but thrombocytopenia is seen. Impression: Dysmyelopoiesis in MDS.

Thank you very much revered madam for your valuable interaction and participation.
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hyper segmented neutrophil(>5lobes)-vit-12 deficiency, Neutrophils showing toxic granules and vacuolation-severe bacterial infections and also band Neutrophils

Thank you very much revered sir for your valuable interaction and participation.
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Revered madam this is not a PELGER -HUET CELL!! Look carefully it is a segmented neutrophil.

@Dr. Monideepa Chattopadhyay madam, check this neutrophil in question. It is not a pseudo-pelger heut anomaly!!! Thanks
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Revered Dr. Yashaswini madam this is another picture showing macrocytes!!

Fig 1 Neutrophils with toxic granules, seen in Sepsis and infections.

sir...I agree with the toxic granules but what about the reduced platelet count and presence of pelger huet like cell in figure 2...even though there is hypersegmented neutrophil the RBC' S morphology look absolutely normal....can we think of vit b12 deficiency here...and taking everything in to consideration can we come to a probable diagnosis with this peripheral smear??? kindly enlighten us... thank you in advance...

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