"Tearful" red blood cells, have you noticed?

foreword

Mature red blood cells have various forms, one of which is called teardrop-shaped red blood cells, which is shaped like a teardrop, and is abbreviated as "tear-like" red blood cells.

case after

A 46-year-old female patient was admitted to the emergency department on June 23, 2022 due to "abdominal pain for more than a month"

Physical examination: T: 37.

B-ultrasound check:

Blood routine: The results showed high white blood cells, anemia, high platelets, and abnormal scattergrams.

Blood film: see blast cells, immature granulocytes, nucleated red blood cells and teardrop-shaped red blood cells.

Oil glass shown (×1000)

Peripheral blood smear report

Bone marrow smear: good material, active bone marrow proliferation, the same shape as blood smear

Oil glass shown (×1000)

Bone marrow smear report

FISH inspection results: BCR/ABL translocation probes within the detection range showed atypical fusion signals, with a positive rate of 98.

FISH inspection

Cytogenetics:

Karyotype analysis showed 46,XY,t(9:22:11)(q34:q11.

karyotype analysis

BCR/ABL1 (P190, P210, P230) test results: negative

BCR/ABL1 fusion gene (rare type) qualitative test result: (el3a3 type) positive

Bone marrow biopsy results: morphologically consistent with myeloproliferative tumor, considering primary myelofibrosis (MF-2, collagen fiber-2, osteosclerosis-0)

Bone marrow biopsy

JAK2V617F mutation qualitative test result: negative

case analysis

A 46-year-old female patient complained of abdominal distension for more than one month

The bone marrow smear was taken well, but the proliferation was active, but not significantly active, unlike the typical CML bone marrow morphological characteristics, and individual teardrop-shaped red blood cells were also seen, so it was considered as a myeloproliferative neoplasm (MPN) from the morphological point of view.

Subsequent FISH results indicated the presence of the atypical fusion gene BCL/ABL, with a positive rate of 98%.

At the same time, bone marrow biopsy was also consistent with myeloproliferative tumor, but suggested primary myelofibrosis (PMF), and the qualitative test for JAK2V617F mutation was negative, which did not support PMF

knowledge development

1.
Myeloproliferative neoplasms are a group of clonal hematopoietic stem cell diseases characterized by the persistent abnormal proliferation of relatively normal differentiation and maturation of one- or multi-lineage myeloid cells in the bone marrow
.
Including chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET), primary myelofibrosis (PMF), chronic neutrophilic leukemia (CNL) and chronic eosinophilic myeloid leukemia
.

Chronic myeloid leukemia mainly involves myeloid, manifested as persistent and progressive increase in the number of peripheral blood leukocytes, and granulocytes of different differentiation stages appear in the classification, especially neutrophils, often accompanied by reticular fibrosis , but collagen fiber hyperplasia is rare at the initial diagnosis
.

Myelofibrosis is divided into primary myelofibrosis (PMF) and secondary myelofibrosis (SMF) according to the presence or absence of primary disease.
SMF is more common in the course of myeloproliferative diseases (CML, PV, ET).
Especially late
.

There are extramedullary hematopoiesis in bone marrow fibrosis, and characteristic teardrop-shaped red blood cells, nucleated red blood cells, immature granulocytes and giant platelets can be seen in blood films.
After hyperplasia, it protrudes into the sinus, the sinus cavity shrinks, and the red blood cells are blocked and deformed into teardrops
.
There are reports that teardrop-shaped red blood cells can disappear after splenectomy [3]
.

2.
The difference between myelofibrosis and chronic myeloid leukemia is as follows:

The difference between MF and CML

Summarize

Professionals engaged in blood cell morphology in the laboratory should not form a fixed mode of thinking, but should be discerning, grasping small key points, divergent thinking, and broadening their thinking
.
For example, in chronic myeloid leukemia and myelofibrosis, the peripheral blood images have similar characteristics, but there are also small key differences.
If you catch a small number of characteristic teardrop-shaped red blood cells at the first time, you can avoid easily falling into the "red blood cells".
In the fixed thinking diagnosis of "slow granules", morphological missed diagnosis or misdiagnosis occurred
.

Therefore, when we encounter splenomegaly, abnormal blood picture, and blasts, immature granulocytes and nucleated red blood cells in peripheral blood smears, we must pay special attention to whether there are teardrop-shaped red blood cells in peripheral blood smears.
The presence of erythrocytes, such as the normal morphology of the background erythrocytes, can further highlight the clinical significance of teardrop-shaped erythrocytes
.
Therefore, it is easier for us to understand and remember teardrop-shaped red blood cells as "tear" cells
.

references:

[1] Shen Ti, Zhao Yongqiang.
Diagnosis and curative effect criteria of blood diseases［M］．4th edition.
Beijing: Science Press, 2018: 131-137.

[2] Gao Haiyan, Liu Yabo, Lv Chengfang, etc.
Clinical examination and diagnosis of blood diseases［M］．First Edition.
Beijing: China Medical Science and Technology Press, 2021: 190-194.

[3] Zhang Zhinan, Shen Ti.
Diagnosis and curative effect criteria of blood diseases［M］．3rd edition.
Beijing: Science Press, 2007: 260-263.