Knowledge Lab

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Welcome to today’s Tale from the Lab. Maximizing diagnostics. Blood cell conundrum.

I like to brag about that.

Mac is a 12 year old male neutered hound mix.

Mac came to us on referral. And again, whenever we have these interesting cases, I always love to go back to the medical record system and find out, like, what did the owner make the appointment for?

He was referred to us for, quote, irregular spleen, comma, possible lymphoma, end quote.

And he is a sighthound. So he is thin. He’s a greyhound mix. Yeah.

So they may have palpated this irregular spleen. Now that we have seen it, actually, it might actually have been palpable, but I have a feeling that they identified it on ultrasound based on the unique ultrasonographic features that we saw.

Um, and I’m guessing he had no other indication of peripheral lymphadenopathy. So I have a feeling that possible lymphoma was just based on them believing there’s infiltrative disease of the spleen.

And when you say lymphadenopathy, what do.

You mean irregular lymph nodes? Irregular or enlarged lymph nodes. So I think his peripheral nodes palpated normally.

Thank you.

So when we saw Mac, I remember distinctly identifying that he had been in the prayer position with his elbows down, stretching out his abdomen, his hips in the air, because his abdomen was so uncomfortable for the entire time during his initial workup and that, you know, they drew blood, he was back in the room.

He was back in that position of stretching out his abdomen.

Can you just imagine how much that would have to hurt, trying to, like, get in any position to make it feel better.

Yeah, that he would sit there stretched out like that. Okay, so he had a history of being anorexic and lethargic for the owner. And on physical exam, other than being uncomfortable in response to abdominal palpation, I don’t think there were any other significant abnormalities.

Yeah, he really just. That prayer position was really the biggest thing. And his stature, like his size and how, you know, long and narrow he is, made it even more Pronounced to see in the room.

It was dramatic. Yeah. So we start with his cbc. It was really surprising when we found out how sick he was,

how few parameters were out of the reference interval on the cbc. We will find out in the blood film that that doesn’t carry through to the blood film. Right. And why, of course, we always want to pair the blood film.

Right. With the cbc, especially in our sick patients. In the leukogram, he did have while no traditional inflammatory leukogram with a leukocytosis and a neutrophilia, meaning increased total white cell count.

Increased total neutrophil count. He did have bands identified. Right. And so that is really. And we’ve had other talks about this, but the hallmark of inflammatory disease.

Yeah. I think the other thing that’s important to point out on his results from his hematology analyzer is that the data in the leukogram is asterisks.

Yeah.

Which is not an indicator that the analyzer didn’t do its job. It’s trying to tell you, hey, something is going on. You need to take a look at this.

Yes. Right. So really helpful information that the analyzer is providing additional information in addition to doing its best guess on what these numbers are in the. In the white cell differential.

It’s letting us know based on our analysis. And we’re trained on healthy animals. We know some of your cells are not typical. And you need to look at a blood film review.

Yeah. So I think it’s really important that if your analyz, in fact, report something like that, that you don’t just ignore it or assume that the analyzer did something wrong. It’s actually doing something really right by saying to you, hey, this is not normal.

We need. You need to look. I need human eyes to look at this.

And that’s especially important at point of care. Right. Because at the reference lab, those same flags trigger a review of the blood film or looking at cell vision using some automated technologies in order to.

To provide a more accurate differential and comment on cell morphology. But without that reference lab quality control. Right. That gives you a more accurate differential and tell you about cell morphology that rests on us as the laboratorians at point of care.

Without going into depth too much, I think the most important thing is if your analyzer does report those types of graphs or images that you know what a normal is, whether that’s, you know, you grab a spay or a neuter that’s healthy and have that kind of as a reference point or oftentimes the manufacturers will have some type of,

you know, educational materials that will allow you to see what quote unquote normal is. Although that’s tricky because what’s normal, but if you at least have a starting point to say this is what it should look like, and then compare that to what you have on on your actual printout.

So important. Right. So to really maximize that information at point of care on hematology in particular, is to know your analyz inside and out. Right. In particular, how the data is displayed to you.

So you know what the asterisks mean or dashed out, unreported data or a flag or a lack of flags or how to look at the scattergrams, et cetera. Correct. Yeah.

So in review for Mac,

no significant abnormalities numerically in the erythrogram platelet parameters also within the reference interval. But we do recognize both inflammation from the identification of bands that were reported. A monocytosis in support of tissue destruction and a superimposed stress response.

Right. That decreases lymphocytes and eosinophils.

Great.

So given the asterisk data in particular,

we know we need to look at a blood film and that really ends up being the crux in his case that we identify on that blood film. So again, images that we will share on our website and on Instagram because it is pretty exciting.

Yeah, it is really exciting.

Noted across his blood film was that he had some large nucleated cells with a big round nucleus and prominent purple granules. This was in a round nuclear cell that was not a lymphocyte.

Too much cytoplasm, too big.

Not a monocyte round nucleus. And those purple granules. When I first saw the first one back in the body of the smear, I really didn’t know. When I got out to the feathered edge and I could see more of the nucleated cells because some had been concentrate or push to the feathered edge.

They were mast cells in circulation.

Yeah, Right. There was a retrospective study looking at mastocythemia in dogs and cats. So increased mast cells and circulation, which is any. Right. There’s not. They’re not normally there in circulation.

For dogs,

most commonly those that had mast cells in circulation, it was associated as a non specific inflammatory response. So associated with other inflammatory disease. Having nothing to do specifically with mast cells.

They just got some out in circulation.

They compared those with the dogs who actually had mast cell neoplasia and that subset of dogs actually had the lower numbers of mast cells in circulation.

That’s Weird.

Am I clear? Right. So in general, it’s almost backwards. You would think. You would think he had known inflammatory disease. So I would like to think I could write it off, because I occasionally, a handful of times a year, doing a white cell differential on a blood film will find a scattered mast cell.

But he had a population of mast cells. And so while I know it’s not supposed to be neoplastic in the dog, I was worried that it may be for him in cats.

It was the opposite. And cats who had mast cells in circulation were, in this study associated with cats with mast cell neoplasia.

Okay. Yep.

So that’s what we’re dealing with with Mac’s case, the concern of systemic inflammatory process. Are we worried about GI compromise? Take a look at the gut, especially with his abdominal pain.

And now we have mast cells in circulation, which, again, if you read the books, should have been nonspecific inflammatory response. But we’re concerned that he might have mast cell neoplasia.

Do you want to see. Want to comment on what we found on imaging?

Sure. Because I was probably holding feet.

Yeah.

So when we went to ultrasound, and a lot of times these things are happening kind of in tandem, which is one of the really nice things about where your microscope is located in.

It’s located in ultrasound, so you can kind of talk as. As you’re looking. They’re also looking with. With the ultrasound.

So we found an irregular spleen. And we’re not radiologist, but it. It was very, like, bumpy and modeled looking.

So not normal at all.

Yeah. Really? You like, very regularly nodular throughout the surface. Scallop margin all around it.

Yeah. Very strange. I’d never seen that. And then also we found some ascites.

Yeah. Which is when we get so excited about, like. So we’re going to do a part two to this where we do we talk about the effusion analysis, because that helps tie his whole case together.

But what an opportunity. We feel like, as the diagnosticians, when they’re ultrasounding a patient and they hit a fluid pocket. I know that. What an opportunity to sample that fluid and get a minimum.

Use a minimally invasive technique to get a wealth of information that’s otherwise hidden inside the patient. Yep. That can tell you whether surgical or non surgical. Is it because of liver failure?

Is it because of heart disease? Or is it because of, you know, a perforation or neoplasia?

Yeah. And in this case, we have mast cells in circulation.

Like, I’m already, like, dying to know what’s in this Fluid. You know, here we have this abnormal spleen. We have ascites. We have a dog with inflammation, you know, circulating mast cells.

He.

He’s in a prayer position.

Possible lymphoma.

Yeah.

Like, initial referral.

What is going to be inside that fluid?

Like, should give us some answers.

Yeah, right. Killing me when we have that to like get out of ultrasound and get into the lab to start processing the flu.

Yeah, it’s very exciting. And again, why will our subsequent episode will be on like what you can do at point of care to get some answers off of your fusion like now.

So we’re going to leave you with the. The doctor sticking the needle into the ascites, pulling it out. I’m going to put it in an EDTA tube because the EDTA preserves the cells.

So that’s our one tube. Hopefully we get enough to have our bonus tube, which is a non additive top tube. So you’re going to want to fill it with whatever is appropriate.

You know, however much you have left, you want to make sure your EDTA tube is filled up appropriately. We talked about that in the blood film technique. Little tips and tricks.

So you want to make sure it’s filled up appropriately. Whatever’s left. If you have some, put it in a white top. You can use it for things like culture, chemistry analysis,

pcr. So we have a lot of options for that. Non additive top tube.

Okay, that’s. That’s maximizing diagnostics.

Blood cell conundrum.

Take home points from max case recognizing inflammation. Right off of hematology. Right. It’s a combination of looking at that leukogram. Right. Not always a classic inflammatory leukogram with a leukocytosis with a neutrophilia.

Right. Maybe a monocytosis asterisk. Data means you need to look at a blood film. If you have bands reported. That’s a gift. Right. You may get that from the reference lab.

Certainly not always at point of care. And the importance of looking at a blood film to verify a more accurate differential. And in this case, without that blood film, we would not have recognized his mastocythemia, which certainly ends up playing into his diagnosis.

All right, join us next time for part two.

It’s gonna be so good.

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Tales from the Lab is a production of Antech Diagnostics. The intent of this podcast is to provide education and guidance with the understanding that any diagnostic testing and treatment decisions are ultimately at the discretion of the attending veterinarian within the established veterinarian patient client relationship.