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Autor*: A. Buliková, J. Kissová
Description:
46-years old male patient with 2-3 weeks long history of sore throat, fever and bleeding symptoms. In CBC is mild normocytic anemia (Hb 100g/l, MCV 91,6 fl), normal leukocyte count (WBC 5,0 G/l) and moderate thrombocytopenia (44 G/l). Only borderline coagulopathy is find (PT 1,32R, normal parameters in aPTT and fibrinogen levels). Leukocytes' differential blood count shows some blasts and some other immature granulocytes, macrothrombocytes and occasional cells of erythroid lineage. In bone marrow smears the relative count of myeloblast is increased more than 20% of all nucleated cells and in erythroid lineage and in megakaryocytes more than 50% of the cells are dysplastic. Flow cytometry discovers 30-35% blast of CD34-, CD38+, HLA Dr +, CD 33+, CD 34-, CD13-, CD14- phenotype. Molecular genetic examination shows FLT3/ITD as a probably negative prognostic feature.
Zařazení*:
AML without prior myelodysplastic syndrome
Přílohy*:
Description: Peripheral blood smears show 27% of myeloblasts (upper right) but also some other cells of granulocytic lineage - there is myelocyte at the lower left. 
Description: There are two myeloblasts here - rather large cells with round or oval nuclei, fine chromatin pattern, two to three nucleoli, moderately basophilic cytoplasm without granulation. One lymphocyte lays beside myeloblast at the left side of the picture. 
Description: Two myeloblasts at this next picture document that even in normal leukocyte count (5,0 G/l) circulating myeloblasts represent dominant population in patient's peripheral blood smears. Group of trombocytes (at the left from upper myeloblast) shows marked anizocytosis. 
Description: Myeloblasts represent about 30% of all nucleated bone marrow cells. There is also erythroid hyperplasia here - almost 50% in bone marrow cells differential count. Cells of erythroid lineage show dysplastic features - megaloblastic nuclei, bilnuclear cells or nuclear lobulisation, internuclear bridges, poorly hemoglobinised cytoplasm. These dysplastic features are presented in more than 50% of erythroid cells. 
Description: There are seven myeloblasts underneath the centre of the picture and three proerythroblasts at the upper left. Between these two groups of the cells lies one agranular band and one red mitosis. Two early polychromatophil red cells precursors (upper left) have megaloblastoid nuclear pattern and they are bilobated. Three late polychromatophil normoblasts (to the left and down from the centre) have pycnotic nuclei. 
Description: The myeloblasts are the most frequent cells of the picture, some of them are in mitosis. In erythroid lineage are megaloblastoid features - markedly expressed in two cells at 4-5 o'clock. Hypogranulation is in neutrophils. 
Description: Three myeloblasts are in the lower left; one of them (underneath eosinophilic myelocyte) has some azurophilic granulation, cytoplasmic protrusions and cleft nucleus. Erythroid lineage shows dysplastic features - nuclear lobulisation, karyorhexis and poor hemoglobinization of cytoplasm. 
Description: Numerous myeloblast and cells of erythroid lineage (almost 50%) are dominant populations of the cells of the bone marrow smear. The cells of erythroid series show dysplastic features - multilobularity, non-round nucleus shape (at 11o'clock), megaloblastoid features (at 9 o'clock) and failure of cytoplasm hemoglobinization (at 3 o'clock). 
Description: There are three myeloblasts in the picture, one of them underneath the centre with cleft nucleus. Three immature cells of erythroid lineage (proerythroblast and two more or less mature early normoblasts) belong to cells localized around the picture's centre. At 5 o'clock lays one dysplastic cell of perhaps granulocytic or may be monocytic lineage; it has band-like but really immature nucleus with fine chromatin and clear nucleoli and immature cytoplasm without granulation. Another almost bizarre cell is in the centre, it the most probably belongs in granulocytic series, it has moderately mature nucleus, basophilic cytoplasm almost without granulation but with one digested late normoblast. 
Description: Three myeloblast and six erythroid cells (and one naked nucleus) are in the picture. Two immature erythroid cells with abundant basophilic cytoplasm are megalobasts. At the lower left is one more cell probably of granulocytic lineage; it has a few cytoplasmic a one nuclear inclusions of not clear origin - some of them can be digestive ones after haemophagocytosis (one at 6 o'clock in the cell). 
Description: Immature cells, some of them are destroyed. Bi-lobar and megaloblastoid late erythroblast is at the right from the centre. Two micro-forms of megakaryocytes are underneath the picture's centre. 
Description: Numerous myeloblast and erythroid cells are in the picture. There are some micro-forms of megakaryocytes (from 2 bi-nuclear to 4 unilobular) at the lower part of it. All of the signs in megakaryocytes signify dysplastic changes.