CHART - 1

Cl/h: 8 yrs child admitted with history of abrupt onset of malaise, fever, periorbital edema and
passing cola-colored urine since 2 days. O/E: Pt. is febrile, BP-160/100mm Hg, HR- 85/min,
RR-20/min: Urine examination showed the following features:

Physical Examination: Chemical Examination:

 Quantity : 900 ml/day PH : 7.0
 Colour : Smoky Albumin : present (+)
 Appearance : Slightly Turbid Blood : Present (+)
 Specificgravity : 1.030 Sugar : Absent
Ketone bodies : Absent
Microscopy:
 Puscells : 0-1/hpf Epithelialcells : 0-1/hpf
 RBCs : 10-20/hpf; dysmorphic Casts and Crystals : RBC casts 1-2/hpf

QUESTIONS:

1. What is the diagnosis?

2. What are the causes?
3. What other lab investigations should be done in the above case?
4. What is the prognosis in this case?
ANSWERS
1. Post Streptococcal Glomerulonephritis
2. Develop after infection caused by bacteria called Group A Beta hemolytic Streptococcus.
3. Serological markers – Elevated Antibodies to streptococcal antigens (> 95% of cases),
ASO titers, Swab for C/S, Acute phase proteins (CRP, S.Ferritin, streptozyme test. Urine
analysis - test RBC’s & red cell casts, protein, serum electrolytes (K,Na), CBC, Blood urea
nitrogen, S.creatinine
4. 95 % children recover with conservative therapy. Poor prognosis in Olderpeople. 80%
people who are not treated develop end stage kidney failure
 CHART - 2

Cl/h: A child came with complaints of facial puffiness, periorbital edema & anasarca. Urine
examination revealed marked albuminuria.
Laboratory findings :
Serum biochemical examinations shows hypoalbuminemia and hyperlipidemia

Physical Examination: Chemical Examination:

Quantity : 1400 ml/day Ph : 7.2
Colour : yellow Albumin : present (++++)
Appearance : Turbid Blood : Absent
Specific gravity : 1.030 Sugar : Absent
Ketone bodies: Absent
Microscopy:
Puscells : 2-3/hpf
Epithelial cells : 3-4/hpf
RBCs : Absent
Casts and Crystals : Absent

QUESTIONS:
1. What is your diagnosis?
2. Define the condition and enumerate the causes?
3. Mention any other investigations you would like to do?
4. How is the specific gravity corrected for altered protein levels?
PTO
 ANSWERS
1 What is the diagnosis?
Nephrotic syndrome.-A kidney disorder that causes the body to excrete too much of protein
in the urine.
2 Define the condition and enumerate the causes?
Nephrotic Syndrome is Defined or characterized by massive proteinuria (>3gms/24 hrs),
Hypoalbumenemia (<3gm/dl) & peripheral edema and hyperlipidemia. Caused by kidney
diseases such as
Primary –Minimal change disease (more common in children), membranous nephropathy,
MPGN, Focal segmental glomerulo nephritis, IgA nephropathy
Secondary – systemic diseases such as DM, SLE, Amyloidosis. Systemic infections – viral
(HBV, HCV, HIV)BE, syphilis, leprosy, protozoa, Parasites. Other causes - Hyper sensitivity
reactions caused by drugs like heavy metals, penicillin,tolbutamide, heroin addiction, snake
bite, pollen etc.Malignancies likecarcinomas, myeloma, Hodgkin’s disease. Toxaemia of
pregnancy,Hereditary diseases likeAlport’s syndrome, Fabry’s disease etc.

3 Mention any other investigations you would like to do?

1. 24 hrs urine sample to measure protein levels, Urine microscopy
2. Blood test – Albumin(reversal of A/G ratio), increased blood cholesterol & Triglycerides.
3. Urine analysis – first test used in the diagnosis of Nephtrotic syndrome. Protein – 3+ or 4+
on dipstick, semi quantitative testing by sulphosalicycilic acid test. U/S – to visualise kidney
Renal biopsy.

4 How is the specific gravity corrected for altered protein levels?

For 1 mg raise of protein add 0.001
For 1mg raise of sugar add 0.003
 CHART - 3

Cl/h: A female aged 40 yrs was admitted to the hospital with a history of recurrent fever,
loin pain since 4months. Urine examination showed the following features:

Physical Examination: Chemical Examination:

 Quantity : 2000 ml/day ph : 6.8
 Colour : Yellow Albumin : present (++)
 Appearance : Turbid Blood : present (+)
 Specific gravity : 1.030 Sugar : Absent
Ketonebodies : Absent
Microscopy:
 Puscells : 30-40/hpf
 Epithelialcells : 4-6/hpf
 RBCs : 2-4/hpf
 Casts and Crystals: Pus cell casts seen.

QUESTIONS:
1 .What is the diagnosis?
2 What are the causes for the above condition?
3 What other investigations would you like to do?
ANSWERS
1. Urinary tract infection

2. E.coli, proteus, klebsiella, chlamydia, mycoplasma, Enterobacter, streptococcus faecalis,

staphylococci,Immuno compromised patients, Cytomegalo virus, Adenovirus.Other causes
include Diabetes mellitus, poor personal hygiene, catheter, bowel for incontinence, kidney
stones, some forms contraception,pregnancy,menopause, procedures on urinary tract,
diminished immune system,immobility for a long period, use of spermicides, tampons,
heavy use of antibiotic.

3. Urine sample – for RBC, WBC, bacteria, culture/sensitivity

Diagnostic Imaging tests – U/S abdomen, X ray, CT, MRI, cystoscopy (to visualize UB &
urethra)
 CHART - 4
Cl/h: A 30 year old female presented with a mobile lump in the right breast of 6 months
duration. Fine needle aspiration from the breast lump was performed.

Slide given below:

QUESTIONS:
1 . What is the diagnosis?
2 . What are the other investigations that should be done in the above case?
3 . How do you differentiate benign from malignant neoplasms of breast on clinical examination?

ANSWERS
1. FNAC smears show features of Benign breast lesion - Fibro adenoma of breast (Breast
mouse)

2. U/S, Mammography, core needle biopsy, surgical biopsy, Excision biopsy for HPE.

3. Benign tumours are well defined. Soft – firm in consistency freely mobile (breast mouse)
Malignant lesions – Illdefined, large, immobile, firm to hard in consistency, retraction of the
nipple, ulceration, nipple discharge, Peau’d orange appearance
 CHART - 5

Cl/h: A 48 year old female presented with a hard, immobile, painless lump in the right upper
outer quadrant of the breast. Fine needle aspiration from the breast lump was performed.

Slide given below:

QUESTIONS:
1 .What is the diagnosis?
2 . What are the other investigations that should be done in the given case?
3 What are the special investigations that determine the prognosis in the above condition?
.

ANSWERS

1. FNAC smear – Malignant tumor of Breast (Duct cell carcinoma)

2. Screening tests – Yearly Mammogram of same and other breast. U/S of both breasts, axilla
& abdomen. Trucut / Excision biopsy.

3. Diagnostic tests-

 Most alternative is a biopsy done when mammography, other imaging tests or

physical examination show breast changes.
 Biopsy is the gold standard. Monitoring tests - physical examination, breast self
examination,
 Blood cell counts, bone scan, breast carcinoma index test, X ray chest, U/S, CT,
MRI, FISH
 IHC Markers – for Estrogen & Progesterone receptors (ER/PR), HER2 neu
receptor study. Genetic study – BRCA mutations, Molecular breast imaging PET
(Positron Emmission Tomographic) scan to find out metastasis.
 CHART - 6

Cl/h: A 40 year old female presented with a post-coital bleeding.

Cervical smear given below for interpretation (Papanicolaou x 400)

QUESTIONS
1. What is the diagnosis?

2. What are the other investigations that should be done in the above condition?

3. What are the risk factors for the development of the above condition?

ANSWERS

1. Is a PAP (Papanicolou) smear shows features of carcinoma cervix (HSIL). Caused by

HPV types 16, 18, 31,33 etc.

2. Cervical biopsy using colposcopy, PAP test, HPV DNA test, punch biopsy, Liquid based
cytology (LBC), Endo cervical curettage, Electrical wire loop, LEEP (loop electro surgical
excision procedure), pelvic examination under anaesthesia, conization, core biopsy
staging examination (X ray, CT, MRI, PET, visual examination of Urinary bladder &
rectum)

3. Sexual history – sexually active before 18 yrs, multiple sexual partners, High risk male
partner, weak immune system (Immuno suppressive therapy, HIV infection, HPV
infection), Chlamydia. Pregnancy history (smoking, multiple pregnancies, diet, h/o birth
control pills, exposure to DES in womb, family history etc
 CHART - 7

Cl/h: A 55-year-old chronic smoker with K/c/o Hypertension & Diabetes was brought to
emergency with complain of sudden chest pain & breathlessness since 6 hours. Chest Pain
was retro sternal and radiating to left arm. Pain increases by exertion and reduces by rest.
On Examination: BP - 160/90 mm Hg, HR – 22/min

Findings – ECG shows : ST segment elevation & T wave inversion

QUESTIONS:
1. What is the diagnosis?
2. What are the causes for the above condition?
3. Mention any other investigations you would like to do?
4. What are the complications?
ANSWERS

1.Myocardial Infarction CK), & CK MB(CKMM,CKBB, CKMB) – specific for cardiac muscle
damage.

2. Atherosclerotic causes – 90%

Non atherosclerotic causes – 10% (coronary vasospasm, arteritis, coronary osteal stenosis,
embolism, thrombotic diseases, trauma, outside compression)

3. In addition to ECG changes serum enzyme estimations like

 CKMB2 : CKMB1 > 1.5 is highly sensitive for diagnosis of acute MI after 4 – 6 hrs of
onset of MI. CKMB Disappear from blood by 48 hrs.
 LDH : LDH 1(myocardium specific), LDH2. Ratio of LDH1 : LDH2 > 1 is diagnostic of
MI. LDH rise after 24 hrs, peak in 3 – 6 days and normal in 14 days
 Cardiac specific troponins (cTn – contractile protein present in cardiac & skeletal muscle ,
specific for myocardium).
 Two forms (cTn I and cTn T). after MI reach very high levels after 4 – 6 hrs. cTn I for 7 –
10 days, cTn T for 10 – 14days
 Myoglobin- lack specificity though 1st cardiac marker elevated after MI & excreted in
urine rapidly

4. Arrhythmias (most common), CHF (50% - RVF or LVF or both), Cardiogenic shock, Mural
thrombosis & Thrombo Embolism (leg veins in 15 – 45%), Rupture (upto 5%), cardiac
aneurysm, pericarditis, post myocardial infarction syndrome (Dressler’s syndrome)
 CHART - 8
Cl/h: 14 years male presented with generalized weakness of 4 months duration.
O/E : pallor, hepatosplenomegaly, yellowish discolouration of sclera and high coloured urine since
10 days

Haematological parameters :
Hb % 6 gm% Urine Stool
Reticulocyte count 7% Bilirubin + Stercobilinogen +
Urobilinogen +
Biochemical findings :
Total Bilirubin 10 mg/dl HBs Ag Non reactive
Direct Bilirubin 2 mg/dl Serum Albumin 3.5 gm/dl
Indirect Bilirubin 8mg/dl Serum Globulin 3 gm/dl
Alkaline phosphatase 110IU/L PT 8 sec
SGOT 70IU/L Gama Glutamyl transferase 25 IU/L
SGPT 90IU/L

1. Interpret the peripheral smear given above?

a. Shows Anisocytosis with increased number of schistocytes and spherocytes. NRBc’s are
also seen.

2. What is the probable Diagnosis?

A.Pre- hepatic/ hemolytic jaundice (Unconjugated hyperbilirubenemia)

3. What are the various types of jaundice?

a.Prehepatic, Hepatic and Post- hepatic Jaundice

4. What are the possible causes of this type of jaundice?

Haemolyticanaemias – Intra & extra vascular haemolysis, Ineffective erythropoiesis associated
with increased bilirubin production.Sickle cell anemia, spherocytosis, ThalasemiaPyruvate
kinase deficiency,G6PD deficiency, MAHA (micro angiopathichaemolytic anemia), HUS
(haemolyticuremic syndrome), Severe malaria in endemic countries, Drugs, prolongedstarvation,
sepsis,Hereditary disorders (Gilbert’s syndrome, rigglernajjar syndrome) Acquired defects-
Drugs, Hepatitis, cirrhosis), neonatal jaundice.

5. What are the urinary findings?

Urine examination (vandenberg’s test – Indirect positive test) - ↑ urobilinogen
 CHART – 9

Cl/h: 30 yrs old male presented with history of fever of 2 weeks duration, nausea and high
coloured urine.
O/E: There is enlargement and tenderness of abdomen.

Biochemical findings :

Total Bilirubin 11 mg/dl HBs Ag Reactive

Direct Bilirubin 7 mg/dl Serum Albumin 3.2 gm/dl
Indirect Bilirubin 4mg/dl Serum Globulin 3.1 gm/dl
Alkaline phosphatase 180 IU/L PT > 16 secs responding to
Vitamin K
SGOT 700 IU/L Gama Glutamyl transferase 30 IU/L
SGPT 650 IU/L

Answers
1 What is the type of jaundice?
A. Intra hepatic jaundice.

2. What are the causes of the above condition?

A. Intra hepatic – Hereditary like Dubin johnson syndrome, Rotor’s syndrome, Fibrocystic
disease of pancreas, atresia, cholestatic jaundice of pregnancy.Acquired – viral, alcoholic &
auto immune hepatitis, drugs,sepsis,Cirrhosis, sickle cell disease Medications- Birth control
pills, phenytoin, diaxepam ,flurrezapam Other causes – TORCH, bacterial, parasitic, primary
biliary cirrhosis, alpha 1 antitrypsin deficiency, IBD, galactosemia, Tyrosenemia, liver cancer.

3. What other investigations you would like to do?

A.
Blood tests – CBC, elevated serum bile acids, elevated serum alkaline phosphatase,
Hyperlipidemia, hypo prothrombenemia, LFT’s, clotting screen
Liver biopsy (bile plugs)
Imaging tests – U/S abdomen, MRI, ERCP, tissue sample or liver biopsy
Viral serology – HAV, HBV,HCV
 CHART - 10

Semen analysis:
Period of abstinence : 3 days
Amount : 3 ml
Appearance : Greywhite
Liquefaction : 15 minutes
PH : 8.0
Spermcount : 10 millions/ml
Motility : > 60% of sperms are actively motile
Morphology : > 65 % of sperms are ofnormal

Answers

1 -What is the diagnosis?

A. Oligospermia. The WHO classifies sperm counts at or above 15 million sperm per milliliter
(ml) of semen as average. Anything below that is considered low and is diagnosed as
oligospermia with 35% of abnormal forms & with 35% sluggishly motile.

2 - Mention the indications for semen analysis?

A. 1. Investigation of Infertility
2. Check effectiveness of vasectomy, recanalisation operation.
3. Paternity testing
4. MLC (rape cases) – alleged or suspected rape cases
5. Selection of donors for artificial insemination/ assisted reproductive technology.

3 - What are the instructions that are to be given for collection of semen sample?
A. a. Abstinence for 3 days (2 – 7 days) prior to collection- Higher abstinence is
associated with ↓ motility & lesser abstinence is associated with ↓ count.
b. Label the container with proper name, time and date of collection of sample
c. collection by masturbation (whole sample should be collected in container)–
d. Lubricants or condom collection is not recommended since they can kill the
sperm and affect the test results.
e. Collection through catheter leads to loss of first portion of ejaculate that is
more concentrated hence not recommended
f. In a clean wide mouthed leak proof container
g. Transport within 1 hour to laboratory and keep temperature as close to body
temperature as possible
 CHART -11

Cl/h: A 3 year old was brought to the hospital with a history of fever and vomiting 2 days
duration. O/E: Nuchal rigidity present. The CSF analysis showed the following features.

PARAMETER OBSERVED VALUE NORMAL RANGE

Volume 2 ml
Colour/Appearance Turbid Straw color
Total count 3400 cells/cumm O – 6 cells/ cumm
Differential count Neutrophils 95%
Lymphocytes 5%
Protein 316 mg/dl 20 – 50 mg/dl
Sugar 10 mg/dl 50 – 80mg/dl
Chloride 118 mEq/L 115-130mmol/l
LDH 96.1 IU/L < 80 IU/L
ADA 2.7 IU/L < 10 IU/L

Answers

1. What is the diagnosis?

A. Pyogenic or bacterial meningitis (inflammatory involvement of the meninges).
It may involve the dura called pachymeningitis, or the lepto meninges (pia –
arachnoid) termed leptomeningitis

2. Mention the organisms causing this condition in various ages?

A. Escherichia coli infection is common in neonates, Haemophilus influenza in
infants and children, Neisseria meningitidisin adolescent and young adults,
streptococcus pneumoniae in extremes of age and following trauma

3. Mention any other investigations you would like to do?

A. CSF by doing lumbar puncture. CSF shows increased pressure, increased
protein, normal or decreased glucose, increased leucocytes (neutrophills),
decreased chloride levels. Culture and sensitivity, Gram’s staining
 CHART - 12

Cl/h: A 43 yrs old male was brought to the hospital with complaints of dizziness and vomiting for
10 days fever, headache, and neck stiffness for 2 days. He has past history of TB 10 yrs back and
was treated. CSF analysis showed the following features:

Pandy’s Test

Chemical Examination:

PARAMETER OBSERVED VALUE NORMAL RANGE

volume 2 ml
colour/Appearance Turbid
Total count 1200 cells/cumm O – 6 cells/ cumm
Differential count Lymphocytes 90 %
Neutrophils 10 %
Protein 292.6 mg/dl 20 – 50 mg/dl
Sugar 32 mg/dl 50 – 80mg/dl
Chloride 70 mEq/L 115-130mmol/l
LDH 113.4 IU/L < 40 IU/L
ADA 17.2 IU/L < 10 IU/L
Pandy’s test Positive

Answers
1 .What is the diagnosis?
A. Tuberculosis meningitis. Caused by haematogenous spread of tuberculous infection.
2 . Mention any other investigations you would like to do?
A. Sputum examination, CSF analysis – increased pressure, increased protein, decreased glucose,
Increased leucocyte count (lymphocytes), decreased chloride levels CSF for Gram’s stain, AFB
staining, culture, PCR, CBNAT
3 . How are the CSF samples transported to the laboratory?
A. After lumbar puncture CSF samples should be transported to a lab as soon as possible.
Specimens for culture should be refrigerated or should not be exposed to extreme cold, excessive
heat or sunlight. They should be transported at temparatures between 20 0c & 35oc.Specimens
should be sent in blood culture bottles, sterile screw cap tubes, vaccutainer, transported in leak
proof containers or plastic bags, swabs.Specimens should be tightly sealedMinimum of 2 ml is
collected, should be properly labelled , location, date & time of specimen collection should be
noted and must reach within 4 hrs of collection. CSF can be refrigerated upto 24 hrs, it should be
examined with in 1 hour since both RBC and WBC have limited stability in CSF, cells can rapidly
lyse
 CHART - 13

Cl/h: A 50 yrs old male presented with fever, vomiting and neck stiffness. He has past history of
renal transplantation 1 year back for end stage kidney disease and he is on immunosuppressive
agents. CSF findings are as follows:

Physical Examination: volume : 2ml, Colour/Appearance : clear

PARAMETER OBSERVED VALUE NORMAL RANGE

Total count 36 cells/cumm O – 6 cells/ cumm
Differential count Lymphocytes 100 %
Protein 68.6 mg/dl 20 – 50 mg/dl
Sugar 113.6 mg/dl 50 – 80mg/dl
Chloride 70 mEq/L 115-130mmol/l
LDH 52.4 IU/L < 40 IU/L
ADA 6.7 IU/L < 10 IU/L
Pandy’s test Positive

Answer the following Questions :

1. What is the probable diagnosis?
2. Mention the organisms causing this condition?
3. Mention any other investigations you would like to do & what is the confirmatory test?
4. Describe Indian ink preparation test?

1. A.Cryptococcal meningitis
2. A.Crytococcus neoformans
3. A.CSF findings negative india ink preparation
4. A.Negative staining done by india ink preparation in which refractile clear capsule
surrounded by clear halo is seen since the carbon particles cannot penetrate the capsule
 CHART - 14

Cl/h: A 50 yrs old female complaints of progressive weight gain, fatigue deepening of voice, dry
skin constipation, cold intolerance and bradycardia. On examination thyroid gland swelling is seen
with delayed deep tendon reflexes. Labroratory findings include:

Total serum T4 3.8 ug/dl

Serum free T4 0.3ng/dl
Serum free T3 200 pg/ml
Serum TSH 10 mIU/L

Answer the following questions:

1. What is your diagnosis?
2. What are the various causes for this condition?
3. What are the Normal thyroid profile values?
4. Interpret thyroid profile in this case and come to conclusion?

1. Hypothyroidism

2. Decreased production of thyroid hormone for prolonged priods and increased resistance to
them by peripheral receptors

3. T3 :100-200 ng/dl
T4 :5-12 micro g/dl
TSH: 0.4-4 mIU /l

4. T3 :

T4 :

TSH:
 CHART – 15

Cl/h: A 58 yrs old female complaints of progressive weight gain, fatigue, heavy menstruations
poor memory and myxedema are seen. On examination diffuse swelling of thyroid gland seen with
many associated clinical features as shown in the picture below.

Laboratory findings:

Total serum T4 5.6 ug/dl

Serum free T4 16 ng/dl
Serum free T3 4.5 pmol/L
Serum TSH 6.8 mIU/L

Answer the following questions:

1. What is the clinical diagnosis?
2. What is the etiology & pathogenesis for this condition?
3. Interpret thyroid profile in this case and come to conclusion?
4. Describe histopathology features of this condition?
5. What is the additional biochemical test for this condition?

1. Hypothyroidism, Hashimotos Thyroiditis

2. Autoimmune diseases
3. T3 :
T4 :
TSH:
4. Infiltration of lymphoid cells, plasma cells macrophages on to thyroid follicle,atrophic
epithelial cells are transformed into degenerative state with fibrous thickening
5. Anti thyroglobulin autoantibodies ,Anti-TSH receptor Anti-TPO
 CHART – 16

Cl/h: A 30 yrs old pregnant female prerented with history of generalized weakness and fatigue
since 3 weeks.

Investigations:
 Hb : 4.6gm%
 TC : 5600 cells/cmm,
 Platelets : 4.6 lakhs/cmm,
 PCV : 17.2%,
 MCV : 55.7 fl,
 MCH : 14.9pg,
 MCHC : 26.7g/dl,
 RDW – CV : 20.3%

Answers
1. What are the peripheral smear findings?

A. RBC :Microcytic and hypochromic RBCs with marked anisopoikilocytosis.Few Pencil cells/
cigar shaped red cells, pessary cells (central pallor 2/3 rd to 3/4th of the cell and peripheral rim of
Hb is seen).
WBC :TLC& differential count are normal.
Platelets :Increased
Impression : Microcytic hypochromic Anaemia (Iron deficiency anaemia)

2. What are the causes for the above condition?

A. Dietary deficiency of Iron, Impaired absorption, Increased blood loss, Increased demands,
Genetic forms of iron deficiency anemia, in elderly colon polyps, peptic ulcer disease in males,
menorrhagea, pregnancy in females, hook worm.Other causes include malnutrition, malabsorption,
gastectomy.

3. What is the differential diagnosis?

A. Iron deficiency anemia, Sideroblasticanemia, Thalassemia major, Thasemiaminor, HbE –
thalassemia, Anemia of chronic diseases & Lead poisoning.

4. What investigations are advised for above condition?

PS, Red cell indices (MCV,MCH, RDW), S.ferritin, S.Iron, TIBC, Transferrin saturation,
Bone marrow aspiration.
 CHART – 17

Cl/h: A 30 year old male with ileal resection done 2 years back presented with anaemia.

Peripheral smear & Bone marrow findings given below:

 Hb : 5.8gm%,
 TLC : 2300/cmm,
 RBC : 1.16million/cmm,
 Platelets : 1.66lakhs/cmm,
 PCV : 15.8%.
 MCV :136fl,
 MCH : 50 pg,
 MCHC : 36.7 g/dl,
 RDWCV : 18.6%

Answer the following questions:

1. Interpret the bone marrow picture?
A. Bone marrow aspiration smear shows megaloblasts which are larger than normoblasts with
open sieve like chromattin
2. What are the causes for the above bone marrow picture?
A. Vitamin B12 deficiency, Folic acid deficiency, Intrinsic factor deficiency(pernicious
anaemia), drugs like phenytoin, methotrexate
3. What will be the blood picture in this case?
A. Peripheral smear – moderate to marked anisopoikilocytosis,Macrocytic RBC,
Hypersegmentedneutrophils,Decreased RBC count, WBC count, Platelet count, decreased
reticulocyte count, nucleated RBC’s Evidence of dyserythropoeisis – basophilic stippling,
cabot rings, Howel jelly Bodies
 CHART – 18
Cl/h: A 12 year old female child with repeated painful swelling of the hands and feet.

PERIPHERAL SMEAR GIVEN BELOW:

Answer the following questions:

1 - What is the diagnosis& what are the PBS findings?

A. Sickle cell anaemia (characterized by the presence of HbS which imparts sickle shape to red
cells in a state of reduced oxygen tension)PBS shows moderate to severe anisopoikilocytosis,
sickle cells, target cells, ovalocytes,polychromatophills, howel jelly bodies.

2- List other investigations necessary for the diagnosis?

B. Sickling test demonstrates sickle cells, Hb electrophoresis – HbS is a slow moving
haemoglobin as compared to HbA. Estimation of fetal Hb (HbF), reticulocyte count, serum
haptoglobin, serum Fe &Ferritin ↑,↑transferin saturation , ESR low, HPLC (high performance
liquid chromatography). Prenatal diagnosis by amniocentesis or chorionic villous biopsy
Family studies – prenatal genetic councelling. Globin chain analysis, HbS Solubility (sickle
Hb is insoluble in deoxygenated state).

3-What are the other clinical features?

A. Generalized impairement of growth(reduced height & weight) Hand foot syndrome – the dorsum
of hands/fee are painful and swollen. Destruction of phalanges, metacarpals, metatarsals because
of vaso- occlusive crisis and dactylitis( bone pain) Acute chest syndrome, Splenic hypo function
(auto splenectomy) – ↑ infections (pneumonia, meningitis) Organ damage (spleen , heart, kidney,
lungs) Leg ulcers, cardiomegaly, hepatomegaly, gall stones, abdominal pain, Occlusion of cerebral
vessels results in CNS manifestations, persistent priapism, ocular complications (Salmon patches -
intra retinal hemorrhages, AV anastomoses due to occlusion of retinal vessels) .

4 -Why is the patient having repeated attacks of bone pain?

A. Bone pain is due to vasoocculsion which leads to hypoxic injury and infarction
that causes severe pain in the affected region
 CHART – 19
Cl/h: A 1 year old child presented with failure to thrive and irritability.
O/E: Hepatosplenomegaly were noticed.

INVESTIGATIONS:
 Hb: 5,7 gm %,
 Corrected WBC count: 25,000cells/c.mm,
 DC: N56/L32/M10/E02/B00/
 NRBCs-28/100WBCs,
 RBC:2.33mill/c.mm,
 Hct: 18%,
 MCV: 77.3fl,
 MCH: 24.5PG,
 MCHC: 31.7g%,
 Plt: 1,73lakh/c.mm.

PERIPHERAL SMEAR GIVEN BELOW:

Answer the following questions:

1 .What is the diagnosis?
2. List other investigations you would like to do and what findings do you expect?
3. What are the follow up investigations to be done in case of repeated transfusions in the
above condition?
 1. What is the diagnosis & describe the Peripheral smear findings?
A. Haemolytic anaemia.
The peripheral smear & reticulocyte count are the most important tests to diagnose hemolysis.
PBS shows Nucleated RBC’s which implies ↑ erythropoeisis, plenty of target cells, few pencil
cells, schitocytes (fragmented cells, helmet cells,acanthocytes, triangular cells)

2- List other investigations you would like to do and what findings do you expect?
 A. CBP, PBS, ↑ Serum LDH, serum haptoglobin ↓, ALT ↑ unconjugated or Indirect
bilirubin , ↑rate of bilirubin productuib,
 Urine – haemoglobinuria in Intravascular haemolysis (↑urobilinogen)
 Direct coomb’s test to detect auto immune hemolytic anaemia
 Haemoglobin electrophoresis (helps to diagnose the type of anemia)
 Testing for PNH, Osmotic fragility test if sickle cell anaemia suspected
 Bone marrow aspiration & biopsy

3. What are the follow up investigations to be done in case of repeated transfusions in the above
condition?
A. CBC, to determine platelet count & PBS routinely should be done. G6PD enzyme assay
HPLC for all haemoglobinopathies
 CHART – 20
Cl/h: One day old neonate, peripheral smear and special stain for interpretation.
PERIPHERAL SMEAR SPECIAL STAIN IS DONE:

Answer the following questions:

1. What is your observation?

A. Reticulocytosis - PBS show increase in nucleated RBC’s indicative of haemolyticanaemia.

Specilal stain demonstrating ↑reticulocytes. Rericulocytes are immature erythrocytes and represent
a stage before the development of RBC.
Normal range : Adults : 0.5% - 2% of red cells
Cord blood (infants at birth): 1 – 7%, children upto 5 yrs : 0.2 – 5%

2. List the conditions in which it is increased?

A. Prematurity, post natal hypoxia, erythropoeisis, haemolytic disease of Newborn, haemolytic
crisis, after blood loss or effective therapy for certain kinds of anemia (eg – therapy for iron
deficiency/ folic acid/megaloblastic, macrocytic anaemia, haemolyticanaemia).

3. What is the corrected count of the above cells?

A. Suppose in the above case reticulocyte count in an adult patient with Hb 7.5gm% is 5%. The
formula for reticulocyte correction for anaemia is
Corrected Reticulocyte count = Patient’s Hb X Estimated R.count
Normal Hb value for that age
= 7.5 X 5 = 2.5 %
15
4. What are the investigations to be done?
A. Supravitalstaining : These RBC’s are slightly larger with 20% more volume than red cells and
contain RNA which stains with basic dyes like Brilliant Cresyl Blue and New Methylene Blue,
demonstrating blue filamentous or granular material.Since the RBC’s are stained in a living state
in vitro this staining is known as Supravital staining
 CHART – 21

Cl/h : A 19 yrs old presented with high grade fever with chills & rigors. PS for evaluation.

Answers
PS for evaluation.
PS :RBC: Normocytic normochromic RBC’s.
WBC: Leucocytosis with more than 75% neutrophils
N80% L17% E1% M2% B0%
Platelets: With in normal limits.

1. What is the diagnosis?

A. There is increase in neutrophil count(Neutrophilia)

2. What are the conditions in which above cells are increased and decreased?
A. Newborn, pregnancy, stress, exercise, acute bacterial infections, aute inflammatory diseases,
myeloproliferative disorders, vasculitis, myositis, acute haemorrhage, acute hemolysis, steroid
therapy etc.
 CHART – 22

Cl/h : A 38 yrs old male presented with fever, body pains. PS for evaluation:

Answers

RBC:Normocytic normochromic RBC’s

WBC: Leucocytosis with increase in lymphocytes
DLC: N36%‐ L58%‐ E2%‐ M3%‐ B1%
Platelets: Within normal limits

1. What is the diagnosis?

A. Lymphocytosis

2. What are the causes for lymphocytosis?

A. Tuberculosis, Brucellosis, Syphilis, Hypothyroidism, Viral infections (Infectious
mononucleosis, cytomegalovirus, mumps, measles, chicken pox, HAV, HBV, HCV, HIV/AIDS)
Toxoplasmosis,acutecardiovascularcollapse,trauma,major surgery, Haematological malignancies
like ALL,CLL, NHL.
 CHART – 23

Cl/h : 26 yrs old male known allellrgic patient presented with fever, breathlessness.

PS for evaluation

Answers

Cl/h: 26yrs old male known allergic patient presented with fever, breathlessness.
PS for evaluation.

RBC: Microcytic hypochromic RBC’s with mild anidopoikilocytosis

WBC: TLC with in normal limits with DLC shows eosinophilia
DLC: N47%‐ L19%‐ E32%‐ M2%‐ B0%
Platelets: WNL

1. What is the diagnosis?

A. Eosinophilia

2. What are the physiological and pathological conditions associated with the above disease?
A. Increased in allergic conditions (Asthma, utricaria, Rhinitis, Hay fever) Parasitic infections
(Round worm, hook worm, filariasis,Trichinosis) Skin diseases (Eczema, psoriasis,
Dematitis)Others like tropical & pulmonary eosinophilia, CML, HL, fungal infections,
Loeffler’sSyndrome,drug allergy, Auto immune diseases, Endocrine disorders etc.
 CHART – 24

Cl/h : A 30 yrs female presented with weakness, fatigue, pallor, loss of appetite, burning
sensation in hands and feet. PS for evaluation.

Answer the following questions:

1. Whar is the characteristic peripheral smear finding?
2. What are the causes for the above condition?
3. List the investigations you would like to do?

1. What are the characteristic peripheral smear findings?

A. RBC: Demonstrates macro-ovalocytes, characteristic of megaloblastosis with moderate to
marked anisopoikilocytosis. Macrocytes lack central pallor. Other RBC inclusions like Basophilic
stippling, Cabot rings (8 like structures), Howell jelly bodies (nuclear remnants in few red cells)
WBC :Leucopenia. Hypersegmentation of neutrophils (their presence is a specific indication of
megagloblastic anaemia). Such neutrophils have 6 – 10 nuclear lobes Platelets :Thrombocytopenia.
Impression: Pancytopenia

2. What are the causes for the above condition?

A. Nutritional deficiency of Vit B12 or folate or combined deficiency
Deficiency of intrinsic factor causing impaired absorption of Vit B12 called pernicious anaemia

3. List the investigations you would like to do?

Red cell indices, S. folate, Red cell folate, S. Vitamin B12, FIGLU test, Formamino glutamate
excretion test – Increased excretion in folate deficiency. Methyl malonic acid and
Homocyteine( most sensitive test).Schilling test.Intrinsic factor antibody in serum
 CHART – 25

Cl/h: A 5 year old child presented with fatigue, bone pain and painless cervical and axillary
lymphadenopathy. O/E: pallor and diffuse petechiae.
INVESTIGATIONS:
 Hb: 8.9 gm %,
 Total LC: 45,750cells/cumm
 Platelet count : 25,000 cells/cumm

Peripheral smear given below

Answer the following questions:

1. What is the diagnosis & how will you classify?
A. Acute Lymphocytic Leukemia (ALL –Is the malignancy of lymphoid precursor cells which
originate in the bone marrow or thymus). Types are L1, L2 & L3. 75 – 80% are of B
precursor cells and 20 -25% are of T cell lineage.

2. Describe the cells in peripheral smear ?

A. Increase in WBC count. DC shows 40 – 95% blast cells. Blast cells are large cells with high
N/C ratio; coarse nuclear chromatin with indistinct 1-2 nucleoli.Blast cells may be of L1, L2 or
L3.

3. Which immunochemical stains will be positive in the above case?

A. Lymphoblasts are positive for PAS stain which demonstratesblock positivity.

4. Which are the factors associated with unfavorable prognosis?

A. worse / unfavourable prognostic factors
a. Black race, Age < 2 yrs (children <I yr and adult > 10 yrs)
b. Presentation in adolescence or adulthood.
c. Male, meningeal involvement, lymphadenopathy, massive hepato and splenomegaly
d. PS – blood count > 50000 to > 100000/cumm
e. L2, L3 – unfavourable (L1 – good prognosis)
f. Immunophenotype – T ALL in children
g. Increased LDH
h. BCR – ABL fusion gene +
Favourable prognostic factors: Age between 2 – 10 yrs, Low WBC count, hyperploidy.
 CHART – 26

Cl/h: A 20 year old male presented with a history of bleeding gums.

INVESTIGATIONS:
 Hb: 8 gm %
 TLC: 92,000 cells/cumm
 Plateletcount: 70,000 cells/cumm

PERIPHERAL SMEAR GIVENBELOW:

Answer the following questions:

1 - What is the diagnosis& how will you classify?
A. Acute Myeloid Leukemia (AML). It accounts for 80 -90% of acute leukemias.
More common in adults with increased frequency as the age advances.
FAB classification :
M 0 – Undifferentiated with only < 3% MPO +ve
M 1 - Maturation& show Medium to large blasts with >3% MPO +ve
M 2 – 3 – 100% Blasts are MPO +ve, along with promyelocytes, myelocytes, with Auer rod
M 3 – promyelocytes with multiple Auer rods, heavy staining on MPO
M 4 – Blasts are > 30% on non – erythroid cells
M 5 – Monoblasts are > 80% of bone marrow and are MPO -ve
M 6 – Blasts are > 30% of bonemarrow and erythroblasts are > 50% of bone marrow cells
with PAS +vity
M 7 – Megakaryoblasts are CD 61 /CD 41 +ve

2. Describe the cells seen in the picture?

A. Presence of Myeloblasts. Myeloblasts are large cells and have increased N/C ratio with
moderate amount of cytoplasm with high N/C ratio. The nuclei have fine open chromattin&
presence of 2 -5 nucleoli. Presence of Auer rods.

3. What percentage of blasts should be seen in acute leukemias?

A. Myeloblasts - 20 % (blasts constitute 10 -100% of the white cells) Myelocytes, promyelocytes,
megakaryoblasts PS :> 10 % of blasts, Bone marrow :> 20 % of marrow cells
4. What is the cytogenetic abnormality seen in AML M3 & what is its significance?
A. Cytogenetic abnormality: t C15 :17 (q22 : q21) in AML M3

5. Which immuno chemical stain will be positive in the above case?

A. Cytochemistry : MPO (Myeloperoxidase) positive in AML except M0, M6 & M7 NSE (Neuron
specific enolase) positive in AML M4 & M5.
CHART – 26
 Cl/h: An elderly female patient presented with fullness of abdomen, dragging pain since seven
days. History of fatigue anorexia, weakness, weight loss, night sweats and low grade fever with
loss of appetite were present. On ultrasonography, massive splenomegaly was noted.

Laboratory findings showed raised serum uric acid and serum LDH and decreased LAP score.

Gross image of spleen, peripheral smear study, cytogenetics study images were shown below.

Based on the clinical details, lab findings provided Answer the following questions:
1. What is the diagnosis?
2. Discuss peripheral blood smear, bone marrow, biochemical findings?
3. Discuss about characteristic chromosomal abnormality associated with this condition?
4. What is the WHO classification?
5. What are the different phases of above condition?

1. What is the diagnosis?

A. Chronic Myeloid or MyelogenousLeukemia (CML)

2. Describe the cells in the peripheral smear?

A. PBS shows – all myeloid series of cells including predominantly neutrophills, metamyelocytes,
myelocytes, promyelocytes, band forms, basophils, eosinophils. Myelocytes are the characteristic cells
accounting for 10 -50% of WBC, myeloblasts 1 – 10%

3. How do you classify the disease?

A. There are 3 phases
a. Chronic phase– Stable phase lasts for 2- 6yrs, Blasts are usually 2 – 5% in blood/bonemarrow. It
may gradually transform to accelerated phase
b. Accelerated phase – more aggressive phase, lasts for a few months and usually transform into
blastic phase. Leukemic cells show increasing loss of differentiation and maturation. Blasts are > 10%
but < 20%, basophils 20%, Hb<7 gm/dl, platelet < 1 lakh or > 10 lakhs /mm3 and unresponsive to
therapy, NAP score may increase
c. Blast crisis –Blasts > 20% in blood or bone marrow(WHO), may be myeloid type (70% cases) or
lymphoid type (30 % cases). Transformation to acute leukemia and the disease becomes extremely
resistant to chemotherapy. lasts for a few weeks – months, lymphadenopathy may appear, marrow
fibrosis may result in marrow failure, granulocytic sarcomas may develop, extra medullary blast
proliferation, thrombocytopenia results in bleeding episodes, foci of blast. cells are seen in bone
marrow biopsy

4. What is the genetic abnormality in the above case?

A. Translocation of t 9 : 22 (Philadelphia chromosome).
ABR – BCL gene ( Abelson Leukemia Virus ) - Break point Cluster region)

CHART – 27
 Cl/h: A female patient aged 60 years came for annual routine checkup.
O/E: generalized lymphadenopathy and hepatosplenomegaly were noted.
INVESTIGATIONS:
 Hb: 9 gm %
 TLC: 90,000/cumm
 Platelet count: 1.2lakhs/cumm

PERIPHERAL SMEAR GIVEN BELOW:

Answer the following questions:

1. What is the diagnosis?
A. Chronic lymphocytic Leukemia (CLL) – Is a haematological neoplasm characterized by
proliferation and accumulation of relatively mature appearing lymphocytes in blood, bone
marrow, lymphnode, spleen, liver and other organs
PS - showing marked proliferation mature lymphocytes (70 -90%) mostly small which have a
thin rim of cytoplasm. Sometimes there may be medium sized lymphocytes &lymphoblasts with
presence of smudge cells (damaged cells while preparing the film with bare nuclei).
2. How do you stage this disease? What is the stage in the above case?
A. There are two types of staging
Binet stage –
1. < 3 lymphoid areas enlarged
2. > 3 lymphoid areas enlarged
3. Anaemia (Haemoglobin< 10 gm/ dl
4. and/or thrombocytopenia (Platelet count < 1 lac/mm)
Rai stage:
0 :Lymphocyosis only
I : lymphadenopathy
II : Hepatomegaly and/or splenomegaly + lymphadenopathy
III :Haemoglobin< 11 gm/dl
IV : Platelet count < 100000/ cmm
3. What are the favourable&unfavourable prognostic factors ?
A. Favourableprognostic factors: Early stage disease , predominance of small mature
lymphocytes, nodular marrow infiltration, normal karyotype or 13q, antigen CD 38, normal B2
microglobulin, mutated IgVHgene, LDT > 12 months.
Unfavourableprognostic factors: Advanced stage disease, > 10% prolymphocytes, diffuse
marrow infiltration, 11q, 12+, 17p, antigen CD 38+, elevated B2 microglobulin
CHART – 28
Cl/h : 56 yrs malel presented with progressive anaemia, fatigue, weakness and bone pains. O/E he
has pallor, pathological fractures of vertebra and cord compression
Laboratory findings:
 Hb : 8 gm/dl ,
 TLC : 10000/cmm,
 ESR : 110mm/1st hour
 Serum Calcium : 12.5gm%,
 Serum Creatinine : 2.5 gm% and
 Bence jones proteins in urine.

Answer the following questions:

1. What is your diagnosis & what are the criteria for the diagnosis?
2. What are the findings in peripheral smear, bone marrow aspiration and bone marrow biopsy?
3. What are the other investigations?
4. What is Bence Jones proteineuria? What is its importance?

1 - What is the diagnosis?

 A. Bone marrow aspiration smears – Multiple Myeloma.
Aspiration smears showing increase in plasmacytoid cells.
Myeloma cells > 10%of marrow cellularity. Myeloma cells have an eccentric nucleus, peri
nuclear haff, pale blue cytoplasm.

2 - What are the laboratory and radiological findings you would expect?
PS – normocytic normochromic anaemia, Red cells rouleaux formation, few atypical plasma cells.
BMA – myeloma cells > 10% of marrow cellularity
Bleeding time (BT) increased (platelets get coated by Mcomponent which impairs platelet
aggregation).
Increased ESR – due to high tumor load
Urine – light chains in urine (Bence Jones protein).

Biochemical tests – S.calcium increased (hypercalcemia) Serum phosphate increased, hyper

uricemia, increased Creatinine

Radiological findings – multiple lytic punched out lesions particularly in skull, spine, ribs,
pelvis, long bones and vertebrae. Electrophoretic studies – M band component of Ig G / Ig D/
Ig A/ Ig E.

3 - How do you confirm the diagnosis?

A. a. Marrow plasma cytosis (>60% of plasma cells in Bone marrow)
b. Free light chain ratio of > 100
c. > 1 focal lesion on MRI (lytic bone lesions in X ray)
d. Demonstration of S para protein M component in Electrophoresis
e. Immuno fixation studies help in confirming the diagnosis

4. What are the prognostic factors?

A. Serum B2 microglobulin increased(4 -9 mg/l) prognostic marker(normal 1- 2.5mg/l).
high levels are associated with high tumour load & poor prognosis.

CHART – 30
 Cl/h: A 22 year oldpresented with fever, chills & rigors.
PERIPHERAL SMEAR GIVEN BELOW:

Answers
1. What is the diagnosis?
A. PBS showing malarial parasite with crescenteric or banana shaped gametocyte of plasmodium
falciparum containing a blob of haemozoin pigment & a thin red cell border is recognized.

2. What are the other causes for the above symptoms?

A.Filariasis, typhoid, pyogenic infections

3. Mention other haemoparasites?

A.Plasmodiumvivax, filarial worm, leishmaniadonovani, trypanasomiasis

4. What other investigations to be done ?

A. Thick film – is a concentration method for malarial parasites and one microscopic field is
equivalent to 40 -50 microscopic fields of a thin smear. Thick film is preferred for mass surverys
for a quick diagnosis.
Gel card test : Plasmodium produces an enzymre (pLDH). Presence of pLDH is detected using
monoclonal antibodies against specific epitopes of LDH in gel cards. Positive test indicates active
infection. Test is quick, sensitive and ideal for field conditions
 CHART – 31
Cl/h: A 42 year old male presented with diffuse swelling of the left lower limb since 10 years.
PERIPHERAL SMEAR GIVEN BELOW:

ANSWERS
1 - What is the form seen in the blood smear?
A. PBS showing microfilaria of wucherariabancrofti
B.
2 - Mention other Haemo parasites?
A. Plasmodium species (commonly falciparum &vivax), leishmaniadonovani,Trypanasomiasis
B.
3. What is the drug of choice for the above condition?
A. DEC (DiethyCarbamazine – brand name is Hetrazan) – which is both microfilaricidal and
active against the adult worm is the drug of choice for lymphatic filariasis.

4- What is the ideal way to collect the blood sample for the above condition?

A. Blood should be collected and peripheral smears for demonstration of microfilaria should be
made preferably between 10 pm – 2am or midnight smears. The microfilaria can be demonstrated in
a. Peripheral smear b Thick blood smear c. Unstained \wet preparation – microfilaria are made out
by their movements causing agitation of the wet smear & can be confirmed by examining under a
low power objective.d. Concertration method – anticoagulated blood is centrifuged, smears are made
from sediment, air dried, fixed in methanol and stained with Romanowsky stain.c. Unstained \wet
preparation – microfilaria are made out by their movements causing agitation of the wet smear &
can be confirmed by examining under a low power objective.