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This patient was diagnosed with myelodysplastic syndrome (MDS) with multilineage dysplasia.


The peripheral blood showed a normal WBC count with slightly elevated eosinophil and monocyte counts, and an invalid result for basophils. The patient had normocytic normochromic anemia with MCV at the upper limit of the reference range and an elevated RDW. The PLT count was low-normal.


The peripheral smear showed marked hypogranularity of the neutrophil granulocytes along with hypolobular nuclei. Slight anisocytosis and large PLT were also observed.


The results above are consistent with MDS, which is a heterogeneous clonal hematopoietic disorder. Typical findings in the peripheral blood include hypogranularity and abnormal nuclear segmentation in neutrophils (Gulati). This dysplasia in the granulocytic cells may have contributed to the invalidation of the basophil count. Anemia is usually present in MDS and is often macrocytic (Invernizzi). This patient had an MCV near the upper limit of the normal range. In MDS, patients may present with a dimorphic red blood cell population that indicates clonality of the disease (Rodak). In this case, the elevated RDW reflects the degree of anisocytosis due to the dimorphic RBC population. Further testing should include bone marrow biopsy, flow cytometry and molecular studies for confirmation.

Numerical ResultsInvalid Data

WBC 7.16 10e3/μL
NEU 4.69 10e3/μL 65.6 % Left Shift
LYM .957 10e3/μL 13.4 %
MONO 1.04 10e3/μL 14.6 %
EOS .416 10e3/μL 5.80 %
BASO .049X 10e3/μL .689X %
IG 0.01 10e3/μL .015 %
NRBC 0.00 10e3/μL
NR/W 0.00

RBC 2.66 10e6/μL
HGB 8.75 g/dL
HCT 26.3 %
MCV 98.3 fL
MCH 32.7 pg
MCHC 33.3 g/dL
RDW 20.6 %

RETIC 24.2 10e3/μL 0.91 %
IRF .329
MCHr 30.9 pg

PLT 177. 10e3/μL
MPV 12.6 fL
%rP 20.5 %

Size vs. polarized side scatter plot
This scatterplot is useful for showing the separation between mononuclear and polymorphonuclear WBC based on their nuclear lobularity and internal complexity. In this sample, the neutrophil population (yellow) and the eosinophil populations (green) are markedly shifted downwards along the PSS axis, suggesting hypo-lobulation and hypo-granulation. The neutrophil population is adjacent to the monocyte population (purple); normally, there is significant gap between those.
FIGURE 2. Volume (RBC):
RBC volume histogram plot
On the RBC Volume histogram, the distribution appears asymmetric, showing a second RBC population characterized by a larger cell volume next to the majority of the RBC. This is sometimes seen in the case of extreme reticulocytosis; this patient, however, only had 0.91% reticulocytes. The second RBC population likely represents macrocytes, which is one of the features of multilineage MDS. The increased variability in RBC size resulted in a high RDW.
Polarized side scatter vs. depolarized side scatter
Eosinophils (green) are differentiated from neutrophils (yellow) in this scatterplot, based on the unique property of the eosinophil granules to depolarize laser light. Both populations, however, are condensed along the PSS axis, not spreading as far to the right as in a normal sample, due to the hypo-granularity and hypo-lobularity.
Alinity h casebook.Myelodysplastic Syndrome. ADD-00061876-v2 2019. p.40-41

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