Bewildering plasma cells

Preface

The plasma cell system is transformed from B lymphocytes, and B lymphocytes can be blastoculated under certain conditions to form protoplasmic cells, naïve plasma cells and plasma cells

Case passed

Medical history: patient, female, 65 years old, fever with fatigue, tolerance for 7 days, skin congestion and blood spots for 4 days

Physical examination: sanity, mental fitness, moderate anemia, multiple ecchymosis visible on the skin of the whole body, no yellow staining

▲Blood routine

▲Biochemical examination

CT examination: double pneumonia; Coronary artery and aorta calcification

▲Bone marrow smear

Bone marrow is used, filmed, dyed and colored, oil (+++), granules (+).

Megakaryocytes were absent from the whole tablet, and platelets were rare

The proportion of plasma cells is so high that we naturally think of one disease: multiple myeloma

Immune typing of bone marrow cells: no CD34+ cells detected, a relative increase in lymphocytes, mainly T cells; About 1.

Bone marrow biopsy: extremely low nucleated cell hyperplasia (hematopoietic area less than 10%), no naïve nuclear megakaryocytes, no significant proliferation of reticular fibers, consideration of aplastic anemia (AA), it is recommended to re-diagnose

Chromosomes: normal karyotype 46, XX [5].

Serum protein electrophoresis and urine protein electrophoresis: no M protein

High-sensitivity PNH flow cytometry: CD59 partially deletion expression of red blood cells accounted for 0.

Initial diagnosis: AA with PNH features

Case studies

In elderly female patients, the three lines of blood cells are reduced, the classification of white blood cells is dominated by mature lymphocytes, the n-cell nexacin anemia, the platelets are significantly reduced, and the first disease that comes to mind is AA

However, the plasma cell ratio is significantly higher, although the morphology is mature plasma cells, but it cannot be determined by morphology alone that they are reactive polyclonal plasma cells

The patient did not have hypercalcaemia, renal function impairment, bone destruction, and the serum globulin was normal, and neither serum nor urine protein electrophoresis detected M protein, and MM

AA and PNH are mutually converted, and this patient has a 10-year history of anemia and has not been systematically examined, so we cannot be sure whether she has typical PNH manifestations

According to the literature [1], both clinical and laboratory tests indicate that the condition is predominantly AA, but a positive laboratory diagnosis with PNH can be diagnosed with AA with PNH features
.
The clinical features of this patient are mainly AA, so the diagnosis is that AA is accompanied by PNH features
.

Knowledge extension

Reactive plasmacytosis (RP) refers to a group of clinical syndromes characterized by bone marrow mature plasma cell hyperplasia caused by multiple causes or primary diseases, common causes are acute and chronic infection, connective tissue disease, allergies, chronic liver disease, malignant tumors, aplastic anemia, acute leukemia, myelodysplastic syndrome and other hematopoietic diseases
.
The proportion of plasma cells in the bone marrow increases, ≥3%, generally ≤ 10%, and a few can ≥ 10%, or even as high as 50% [2].

The main distinguishing point between reactive plasma cell cell and other plasma cell-related diseases is the essence of plasma cells, whether it is monoclonal.

The main diseases of monoclonal plasma cells visible in the bone marrow are as follows[3]:

(1) Multiple myeloma (MM): monoclonal plasma cell of bone marrow, usually ≥ 10%, with CRAB (hypercalcaemia, renal impairment, anemia, bone destruction) and other related clinical manifestations
.

(2) monoclonalgammopathy of undetermined significance (MGUS): serum M protein < 30g/L or 24h urine light chain <0.
5g or bone marrow monoclonal plasma cells < 10%, no CEAB symptoms, is currently considered to be a precursor to
MM.

(3) Smoke-type myeloma (SMM): serum M protein ≥ 30g/L or bone marrow monoclonal plasma cells ≥ 10%, but no CRAB symptoms, is a highly heterogeneous class of asymptomatic clonal plasma cell diseases
between MGUS and MM.

(4) POEMS syndrome: a group of clinical syndromes characterized by multiple system damage, manifested as polyneuropathy, organomegaly, endocrinopathy, monoclonalproteinemia and skin changes, plasma cells are monoclonal in nature, the number < 10
。

(5) AL amyloidosis: a group of diseases manifested as amyloid deposited in the extracellular matrix, causing multi-site tissue and organ damage, and the number of monoclonal plasma cells in the bone marrow is uncertain
.

Summary

In recent years, medical laboratory diagnosis technology has undergone rapid changes, and blood diseases rely on MCM comprehensive diagnosis, which not only makes the diagnosis more accurate, but also provides direction
for the treatment and prognosis of patients.
Cell morphology acts as a "pioneer officer" and can still not be ignored, which can provide ideas
for the direction of disease diagnosis.
For example, in this case, we found plasma cell plurisification, although its nature cannot be determined, but we must think of diseases related to plasma cell cell plurisation and then make a differential diagnosis through other tests
.
Cells are not static, we can't limit our thinking to a disease, and we can gain more knowledge
by opening up our thinking.

References

Red blood cell disease (anemia) group, hematology branch of Chinese Medical Association.
Diagnosis and treatment of paroxysmal nocturnal haemoglobinuria in China[J].
Chinese Journal of Hematology,2013,34(3):276-279.

[2] Wang Jianzhong, Zhang Shimin, Liu Guijian, etc.
Atlas of Clinical Laboratory Diagnostics (1st Edition).
Beijing:People's Medical Publishing House,2012.

Xu Wenrong, Wang Jianzhong.
Clinical Hematology Tests (5th Edition).
Beijing:People's Medical Publishing House,2012.
]