The blood film was leucoerythroblastic with left shifted granulocytes and nucleated red cells. There were tear drop cells with red cell anisopoikilocytosis and enlarged platelets.
A leucoerythroblastic film can be seen in the following:
- Marrow infiltration (haematopoietic and non-haematopoietic malignancy, Gaucher’s)
- Severe sepsis/inflammation/haemorrhage
- Massive haemolysis
- Myeloproliferative neoplasms – usually myelofibrosis or chronic myeloid leukaemia (with the latter would usually see basophilia)
- Sickle cell crisis
- Thalassaemia major
- Severe megaloblastic anaemia
The tear drop cells point towards a malignant cause. On examination the patient had splenomegaly. The following genetic markers are useful in the evaluation of myeloproliferative neoplasm:
- JAK2 V617F
- MPL W515L
- CALR exon 9
- BCR-ABL1 (t(9;22))
This patient had a mutation in CALR and a bone marrow trephine confirmed a hypercellular marrow with clustered/hyperlobated megakaryocytes and reticulin deposition. After failing to get symptomatic benefit from hydroxycarbamide he was started on ruxolitinib with good effect but with initial increasing transfusion requirements. Given his age and DIPPS plus score of three was referred for potential haematopoietic stem cell transplant.
- Myelofibrosis prognosis: http://bloodref.com/myeloid/mpd/myelofibrosis-prognosis
- Diagnosis and managament of myelofibrosis http://www.b-s-h.org.uk/guidelines/guidelines/diagnosis-and-management-of-myelofibrosis/
- JAK2 inhibitors in myelofibrosis http://www.b-s-h.org.uk/guidelines/guidelines/use-of-jak-inhibitors-in-the-management-of-myelofibrosis/
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