Assignment Task

Case 1

Clinical notes:

A newborn with unexplained jaundice.

Full blood count results and blood film

Parameter	Result	Reference range
Haemoglobin	136 g/L	121-191 g/L
Red blood cell count	3.62 x 1012/L	3.34-5.40 x 1012/L
Haematocrit	0.453	0.37-0.60
Mean cell volume		101-117 fL
Mean cell haemoglobin		33.0-38.0 pg
MCHC		310-360 g/L
Reticulocyte count	6.5%	4.0-7.0%
White cell count	13.0 x 109/L	9.6-30.4 x 109/L

Questions:

1. Calculate and fill in the missing red blood cell indices in the table above.
2. Describe the blood film morphology.
3. What is the pathogenesis of the jaundice in this case and how would the jaundice be treated?
4. What is the differential diagnosis in this case?
5. What other immediate immunohaematologic tests should be done to make a definitive diagnosis?
6. Two more specialised tests, that may be useful in this scenario are the osmotic fragility test and the eosin-5-maleimide test. Please describe these tests (i.e. what are these tests) and outline briefly how these tests can be used to make a definitive case in this scenario.

Case 2

Clinical notes:

A 23-year-old pregnant female for routine refugee screening.

Full blood count results and blood film

Parameter	Result	Reference range
Haemoglobin	108 g/L	115-165 g/L
Red blood cell count	5.25 x 1012/L	3.80-5.80 x 1012/L
Haematocrit	0.324	0.37-0.47
Mean cell volume		80-100 fL
Mean cell haemoglobin		26.5-33.0 pg
MCHC		310-360 g/L
White cell count	9.7 x 109/L	4.9-12.8 x 109/L
Platelet count	172 x 109/L	150-400 x 109/L
Blood film

Questions:

1. Calculate and fill in the missing red blood cell indices. 
2. Describe the blood film morphology. 
3. What is the differential diagnosis in this case? 
4. What tests should be done in order to make a definitive diagnosis?
5. Given that patient is pregnant, what other tests should be carried out? 

Case 3:

Clinical notes:

A 23-year-old man presented to his general practitioner (GP) with lethargy and bleeding gums. The GP noted that the patient was pale, had numerous bruises on his limbs and a fine rash on his torso.

Full blood count results and blood film

Parameter	Result	Reference range
Haemoglobin	95 g/L	130-180 g/L
Red blood cell count	2.92  x 1012/L	4.50-6.50 x 1012/L
Haematocrit	0.271	0.40-0.54
Mean cell volume	92.8 fL	80-100 fL
Mean cell haemoglobin	32.5 pg	26.5-33.0 pg
MCHC	351 g/L	310-360 g/L
Reticulocyte count	1.26 x 109/L	20-80 x 109/L
White cell count	3.2 x 109/L	3.5-11.0 x 109/L
Platelet count	21 x 109/L	150-400 x 109/L
Blood film

Questions:

1. Describe the morphology of the cells in the top corners of the field.
2. Describe the morphology of the cell in the bottom left-hand corner of the film
3. What is your provisional diagnosis based on the clinical presentation, the full blood count results and the white blood cell morphology?
4. What further tests should be performed immediately on this patient and why?

Case 4.

Clinical notes:

A 3-year-old male presents to ED with bloody diarrhoea and a rash.

Full blood count results and blood film

Parameter	Result	Reference range
Haemoglobin	92 g/L	110-140 g/L
Red blood cell count	3.58 x 1012/L	3.86-5.00 x 1012/L
Haematocrit	0.28	0.31-0.38
Mean cell volume	78.5 fL	73-85 fL
Mean cell haemoglobin	25.7 pg	25-30 pg
MCHC	327 g/L	310-360 g/L
Reticulocyte count	150 x 109/L	20-80 x 109/L
White blood cell count	18.6 x 109/L	4.9-12.8 x 109/L
Platelet count	27 x 109/L	215-450 x 109/L
Blood film

Questions:

What is the likely cause of the rash in this patient and what is the name given to this type of rash?

Describe the red blood cell morphology in the blood film. 

Describe the white blood cell morphology in the blood film.

What is the name given to this the type of anaemia present in this case? 

Taking into consideration the clinical presentation, the full blood count results and the red blood cell morphology, what is your provisional diagnosis for this case?

What is your responsibility as a medical laboratory scientist when faced with a case like this?

Case 5.

Clinical notes:

A 2-year-old child presenting with persistent pyrexia for two weeks and non-responsive to antibiotics. The patient was subsequently diagnosed with Kawasaki Disease following pathology (below) and other clinical assessments.

Full blood count results and blood film

Parameter		Result	Reference range
Haemoglobin		89 g/L	110-140 g/L
Red blood cell count		3.49 x 1012/L	3.86-5.00 x 1012/L
Haematocrit		0.26	0.31-0.38
Mean cell volume		75.9 fL	73-85 fL
Mean cell haemoglobin		25.5 pg	25-30 pg
MCHC		336 g/L	310-360 g/L
White blood cell count		20.2 x 109/L	4.9-12.8 x 109/L
Neutrophil	72%	14.5 x 109/L	1.1 – 8.1 x 109/L
Lymphocyte	23%	4.6 x 109/L	0.8 – 4.8 x 109/L
Monocyte	4%	0.8 x 109/L	0.2 – 1.3 x 109/L
Eosinophil	2%	0.4 x 109/L	0.1 – 0.4 x 109/L
Basophil	0%	0.0 x 109/L	< 0>9/L
Platelet count		375 x 109/L	215-450 x 109/L
ESR		106 mm/h	1 – 20 mm/h
Blood film

Question

1. What is Kawasaki disease and what is the major complication of this disease? In your response be sure to include the major complication of this disease if there is a delay in its diagnosis.
2. Although the cause of Kawasaki disease is largely unknown, please highlight the current accepted aetiology of its development. 
3. ITPKC is a gene that is associated with an increased risk of the disease. What does it encode for and what is the function of its gene product? In very simple terms, how might this increase an individual’s susceptibility to developing Kawasaki disease? 
4. What are the major laboratory findings (both haematological and biochemical pathology; hint: The blood film above may assist you)?
5. How is it treated clinically? 

Case 6.

Clinical problems:  Thrombosis, Anti-thrombotic Therapy and DIC

Please answer one of the following (i.e. a or b):

a) Warfarin-induced skin necrosis

1. What is Warfarin-induced skin necrosis (WISN) and how does it occur (i.e. how does it develop/what is its pathophysiology)?
2. What are the predominant clinical features?
3. How is it treated? 

b) Neonatal purpura fulminans (NPF)

1. What is NPF and how does it result?
2. What are the primary clinical and haematological laboratory features/findings? 
3. How is the condition managed clinically? 

Case 7.

Laboratory investigation of inherited and acquired bleeding disorders

Please answer part (a) and either (b) or (c) (i.e. answer a, then choose to answer either b or)

a) Echis time and Ecarin clotting time:

1. What are the principles of the tests and interpretation of results?

b) Thrombin time:

1. What is the principle of test and interpretation of results?
2. What are the causes of a prolonged thrombin time?

c) Reptilase time:

1. What is the principle of test and interpretation of result?
2. What are the causes of a prolonged reptilase time?