Itโs
#Me2You
Monday
There are so many things to be in awe and celebrate in life like๐ทblooming tulips, a ๐
#SolarEclipse
, or ๐ป
@YoYo_Ma
cello concertos.
But to me, I am always in awe of our incredible blood donors who take the time to donate day after day. Here are a few of
Every single peripheral smear I have viewed for an acute COVID-19 admission has
#covicytes
: large atypical lymphocytes w/ irregular nuclear borders and distinct deep, blue cytoplasm. In the background of lymphopenia, they are a striking cosmic orb. Do you see them also?
When I was a 1rst year resident, I gave birth to my 6th child on Sept 8. I planned to take 4 weeks off, but developed pneumonia & had to take an additional two weeks to recover.
With all that, I was able to graduate on time, and today, my daughter started 2nd grade ๐ฆ
#timeflies
โItโs a basophil.โ
Back to the hospital after dinner and joined by my 6-y/o daughter for a second opinion and basophil bonding.
CML patient refusing treatment, WBC = 180K, PLT= 700K, basophilia
This is what a bag of granulocytes look like. They are transfused to patients with an ANC<500, evidence of an infection not responding to antibiotic therapy. Thank you to our amazing
@WillYouGive
donors who provide this precious product to our patients in need.
#beyondgrateful
24 y/o w/ h/o of Crohnโs Disease presents w/ worsening fatigue, weakness & dizziness. He has mild abdominal pain, but no signs of bleeding. No transfusion history. Infliximab was discontinued for autoimmune hepatitis. Hb/Hct = 4.4/13.5. ๐๐ฝCheck out his peripheral smear below.
This is the plasma of a patient w/ relapsed
#TTP
, who presented w/headaches. Notice how murky the plasma is. This happens when RBCs are hemolyzed (โฌ๏ธbilirubin). Platelet microthrombi accumulate like little rocks in a stream, occluding & shearing RBCs in the microvasculature.
A 23-year-old woman w/ a history of SLE was admitted to the hospital w/ abdominal pain & headache. Purpura is seen on her chest & thighs. Hb /Hct= 8.3,28.4, PLT= 7,000, LDH = 952, Hapto = <8, Ind Bili = 1.2, Cr = 1.2 PT/INR = 1.3. ๐๐ผTake a look at her peripheral smear.
๐ชPlatelet satellitism in EDTA anticoagulated blood.
EDTA chelates Ca2+, changes platelet membrane and unmasks antigens on platelet glycoproteins GPIIb/IIIa and neutrophils, IgG recognizes them forming a bridge between the two cells.
COVID19+ SCD patient in ICU asked me for a hug. Although, a little hard with my big visor, I gave a strong, firm hug. A reminder that we help treat patients beyond the physical.
This is a unit of COVID19
#convalescentplasma
. Each unit has 200 ml & must be ABO-compatible. Once thawed, it has a 5-day expiration date. Remember to transfuse slowly (100 ml/hour) to prevent
#TACO
since many critically ill patients have underlying cardiac or renal disease.
โ๏ธ Cytokine storm in acute Covid causing ๐surge of myeloid cells to flood into the peripheral blood. Mimics CML ๐ฅธ
๐๐ผCheck out those basophils and covicytes.
As a clinical pathologist who reviews peripheral smears, I may not touch the patient, but I examine the patient. Under the microscope, a dynamic conversation occurs. Many times I am left in prayer, sending blessings of complete recovery, peace and comfort.
#Blooducation
Married for 15 years today to an amazing man, who has relentlessly encouraged me to pursue my dreams through all of medical school, pregnancy (x6), raising children, residency, fellowship and life. The penultimate
#heforshe
A 58-year-old man with a history of ๐ฎmultiple myeloma has positive antibody screen. Check out his antibody identification panel.
๐๐ฝNotice it has a panagluttinin pattern, meaning every red cell tested against the patient's plasma is reactive or agglutinates๐ฉธ
#Blooducation
A 33 y/o physician just came back from a retreat in Sudan. She was interested in starting up her platelet donations but was feeling achy with abdominal pain + cyclical fevers. Take a look at her peripheral smear below ๐๐ผ
Notice the ๐trophozoites inside the RBCs.
๐ฉธ๐คWith tremendous gratitude, I have accepted the CMO position at
@impactlifeblood
. Privileged to join a phenomenal team and donor community dedicated to gift of giving life.
๐๐ผSpecial thank you to Dr. Louis Katz. I have BIGGGGG shoes to fill ๐๐
๐What a treat to have my mother visit and tour the ๐ฅผ๐ฌLab and Blood Bank. Hereโs her advice for those pursuing medicine ๐๐ฌ๐ฉธ๐ฉบ๐ฉ๐ฝโโ๏ธ๐จโโ๏ธ
#Path2Path
๐จ๏ธItโs snowing outside, but itโs nice & warm in the Blood Bank. 23 y/o RhD-negative woman delivered an RhD-positive baby. Take a look at the positive๐ถ๐ผ
#FetalScreen
below. Notice the beautiful rosettes floating which look like โ๏ธsnowflakes.
#PathBoards
#Blooducation
This is a synovial fluid smear from a 7 y/o boy who presented limping with a swollen left ankle, and fever for a week. ๐๐ผNotice the intracellular cocci. Culture grew MRSA ๐งซWright stain.
1/8
62 y/o man presents to the ER with new onset shortness of breath ๐ค
WBC = 225K, Hb/Hct = 12.8/39.3, PLT = 210K and the peripheral smear looks like this๐๐ฝ
#PathTweetorial
#Blooducation
#Apheresis
๐๐ผThis is a gorgeous example of
#rouleaux
: the sticking of 4 or more RBC's that form a stacked coin ๐ฐ appearance. This is due increased positive charged proteins such as immunoglobulins that change the zeta potential that repel RBCS. โDiagnosis ๐ฅ๐ฅ๐ฅ IgG kappa MM.
๐๐ผItโs new SARS-CoV2 IgG test validation time! Running known positive COVID-19 patient samples for presence of IgG antibody. How will this result impact our knowledge of disease prevalence and immunity?
#LabMedicine
#LabWeek2020
#Lab4Life
๐๐ผ ๐งช๐ฉธ๐งฌ๐ฆ ๐งซ๐ฌ
Dedicating today's teaching & effort to my father, Ronald S. Wagner, MD, a"h, who passed away on 4-23-2014. One of the first HIV/AIDS physicians of S. Florida, he taught me how to truly care for the sickest. He always believed that "the world will always need good doctors."
๐ผAn 8-month old baby presented with lethargy and fever. Check out her peripheral smear below ๐๐ผ
โ๏ธWhat do you think flow cytometry showed?
9 y/o boy presents to the ED with dark colored urine, fatigue. He is pale and slightly icteric. His Hb = 6.9, โฌ๏ธLDH + Indirect Bili.
Check out his urine in picture ๐๐ผ
๐Since you are the on-call Heme-Onc Fellow you are paged.
โ๏ธ๐ฉธWhat labs would you order and what is your DDX?
๐ซUnbelievable. Super cool. Outrageous. Amazing. Phenomenal. Fantastic. So incredible. Woo hoo.
๐๐ผThank you
@pathologistmag
๐Congratulations to all the wonderful nominees dedicated to
#pathology
The Pathologist's 2020 Power List is now live! Will you appear in one of this year's four categories? Will your friends, colleagues, family?
Find out now!
#PathPower20
1/10
A 19 y/o # SickleCellDisease asplenic patient presents with fevers and signs of hemolytic anemia. Last week, he received a red blood cell exchange. Check out his ๐๐ฝ peripheral smear below. Notice the โญ๏ธ intraerythrocytic rings (blue arrows)
#PathTweetorial
#Blooducation
My final bow as the
#TMfellow
. Thank you Dr. Blackall for providing your incredible mentorship and training in
#TransfusionMedicine
. Thank you
@aabb
,
#SLUPath
, my colleagues and my friends for your encouragement. Thank you to my family for your endless love and support.
โ๏ธ๐Are you a pathology resident taking call & handling Blood Banking and Transfusion Medicine topics?
Here is a 10-step approach to consider when consulted for a Red Cell Exchange in the context of Sickle Cell Disease. ๐๐ฝFollow the
#Tweetorial
below.
#BloodyOnCall
๐๐ผ Take a look at this very rare, frozen unit of Kpb-negative blood.
Kpb is a member of the Kell blood antigen system and is present on 99% of all donors. Finding Kpb-negative blood is challenging.
๐งRare red cell units can be frozen for up to 10 years in glycerol.
When
Blood Bank Mad Libs.
โ๐ผFill in the spaces.
68 y/o RhD-negative man with myelofibrosis and CKD is transfusion dependent.
History of anti-C, anti-K antibodies.
Now, our patient develops an anti- Kpb antibody. His Hb = 5.9
Oh ____. Finding compatible units will be ________.
This is a pedipack, a small unit of blood aliquoted from the โmotherโ bag and designated for a baby. Volumes for babies are determined by weight. โข๏ธUnits are irradiated. If placed into a syringe, it becomes an open system and expires within 24 hours.
๐คฉSuper proud of my daughter.
Just turned 16.
Today was her first whole blood donation ๐ฉธ๐ช๐ฝ๐ ฐ๏ธ๐ ฑ๏ธ๐๐ พ๏ธ
@impactlifeblood
#BloodDrive
STL
Who could have imagined?
7 years ago, 7 months pregnant w/ my 6th babe, I started my
@SLUHospital
AP/CP pathology residency.
Boy was I excited!
๐คฉMy dream was being realized.
I even was assigned my own microscope.
Could life get any better?
This is what a positive Direct Coombsโ otherwise known as a Direct Antiglobulin Test (DAT) looks like under the microscope. When Ab coats the RBC surface and a Coombsโ reagent (anti-IgG) is added, the cells will stick together, or agglutinate.
Cells donโt wear a name badge๐
To identify blasts ask the following questions:
1 Am I big?
2 Do I have a high N/C ratio?
3 Do I have fine nuclear chromatin?
4 Do I have a prominent nucleolus?
โ Then Iโm a blast!
4 years ago, 6 mo. pregnant w/ my 6th, about to start my residency and closest friend diagnosed with triple - breast ca. Odds were against me to finish & my friend was told she would never have children after chemo. Yesterday, received diploma and today reveled in her son's bris
73 y/o man presents with weakness, SOB and poor appetite for 3 weeks. Physical exam reveals a large, firm prostate. PSA = 850 ๐ฑAdmission labs show a Hb/Hct= 6.7/20.8, PLT =87, WBC = 5.29. Heme/Onc requests a
#pathologist
review on the peripheral smear below๐๐ผ
๐Just E-published!
We hope this Illustrated Review on Viscoelastic Testing will elucidate basic concepts while offering clinical applications for testing. Filled with evidence-based algorithms.
๐๐ผCongrats to my co-authors
@JanHartmannMD
+
@JerroldLevy
.
๐ขHey MS4s, getting ready to apply for
#Pathology
Residency in the virtual setting โ๏ธ ๐๏ธMark your calendars & join us Thurs Sept 24th at 9PM ET for a
#Path2Path
chat to get Tips and Tricks for the virtual interview & learn how to evaluate the fit of a program. ๐Bring a friend
To all my friends and colleagues around the world, wishing you
#ShanahTovah
blessings of sweetness, good health and happiness. May this year be one of togetherness, healing and growth filled with laughter, prosperity and collaborative success. W
๐๐ผThis is a great example of ๐๐จ๐๐ซ๐ฌ๐ basophilic stippling Stippling is a type of RBC inclusion caused by precipitation of ribosomal RNA, a sign in a defect in erythrocytic maturation. They can be seen in nutritional deficiencies, MDS, metal toxicities, + hemoglobinopathies.
A 26-year-old female with a history of SLE and nephrolithiasis presented to the ED with hematuria and abdominal pain. ๐จAdmission Hb =5.3.
A type and screen is ordered.
๐๐ฝCheck out her antibody panel below. Notice it has a panagglutinin pattern = all reagent RBCs are reactive.
My 8-year-old daughter told me that her Mac&Cheese looked like DNA ๐งฌ
Is this a sign of budding pathologist who associates the inner workings of the body with anything related to food?
#pathologistfoodie
#ImAPathologist
76 y/o male presented to ED with severe dyspnea.
Hb= 5.5
Pretransfusion testing performed and found a panagluttin reactivity.
๐๐ผCheck out the peripheral smear below and notice the monomorphic lymphocyte population, smudge cells and rouleaux.
โ๏ธWhatโs causing the anemia?
๐๐ผJoin us tomorrow as we launch the new
#pathelective
.com website filled with a ton of pathology lectures given by experts in the field, including topics in
#TransfusionMedicine
๐ ฐ๏ธ๐ ฑ๏ธโบ๏ธ๐ พ๏ธThese lectures are geared towards med students and trainees and are ๐คFREE!!!!
@cullen_lilley
@KMirza
@HermelinMD
Cullen, I think having "made it" requires MUCH more than a shout out from dopey old me! Thanks for the kind words, though.
@HermelinMD
is the star ๐, I'm just helping her out.
๐คฉBest part of my day? Teaching MS2โs topics in ๐ ฐ๏ธ๐ ฑ๏ธ๐๐ พ๏ธ๐ฉธTransfusion Medicine: pretransfusion testing, blood product transfusion criteria, + transfusion reactions. Energized by your questions and curiosity.
#Blooducation
Critical green inclusions known as โ ๏ธโdeath ๐crystalsโ are blue-green inclusions found in neutrophils. This finding is not to be used to predict mortality but are strongly associated with severe liver injury and lactic acidosis. Peripheral blood. Wright stain.
Day 1. Changing out of my clothes in the garage before I enter my house and wiping down my cell phone and pager with disinfectant wipes. Six excited kids on the other side of that door ready to jump all over me. Have to protect them from what I may have been exposed to today.
72 y/o man with malaise, shortness of breath and fevers๐ค
T wave depression on lateral EKG leads. This is what his peripheral smear looks like ๐๐ผ
Sometimes giving life to another, may save your own.
Donorโs whole blood failed the leukofiltration step.
Triggering a CBC which showed an elevated WBC with lymphocytosis.
Contacted the donor and recommended a Heme/Onc referral.
Low risk CLL diagnosis made.
โบ๏ธProud
A baby underwent repair of multiple cardiac defects. Post ECMO, baby developed a left-side pleural effusion. Take a look at the pleural fluid that was collected.
โ๏ธWhat caused this and what do you think you will see under the microscope?
63 y/o female presented to ED with worsening lower back pain and generalized aches. Fevers and night sweats. She was exposed to a COVID-19 positive colleague at work, but tested negative. She was found to have a significant leukocytosis of 50K. Check out her smear below ๐๐ผ
No need to thaw. Plasma available now!
Low Titer Group A Liquid Plasma for emergency released blood products in trauma resuscitation ๐๐ผ
๐ซ๐ก๐ฃ๐๐๐งจ๐ก
26 Day expiration
Not leukoreduced
Stored in the refrigerator
๐ฌThis is what a warm autoimmune hemolytic anemia looks like under the microscope. Notice the range in RBC sizes from spherocytes to polychromatophilic RBCS. ๐๐ฝ Also, check out the rouleaux and RBC agglutination!
#Blooducation
โฃ๏ธMy Beloved
#Blooducation
Colleaguesโฃ๏ธ
Red blood cells are red
Platelets are blue
Cryo is frozen
Plasma is too
Thank you for spreading the love for Transfusion Medicine, Blood Banking and every bloody thing in between
๐ ๐ ฐ๏ธ๐ ฑ๏ธ๐๐ พ๏ธ๐
62 y/o man, O positive with de novo AML undergoes workup for Hematopoietic Stem Cell Transplant (HSCT). ๐Good news: Sibling with 8/8 HLA match! ๐๐ฝBad news: Sibling is A positive. Can this sibling be a donor?
#Blooducation
#PathTweetorial
#HSCT
Macrophages are one of the first immune cells involved in responding to viral infections. They recognize proteins released by tissue injury & stimulate recruitment via signals (cytokines). Notice the monocyte below w/ toxic vacuolization, a common finding in
#COVID19
patients.
I explained to my children the importance of vaccines and how they work to keep us safe. My 6 y/o followed our conversation with her own illustration of how the vaccine works against Covid-19.
#GirlsInSTEM
#ApheresisChalkTalk
. Today we discussed ๐ฉธpretransfusion testing and why products need to be emergency released such as pRBCs in patients taking the drug
#daratumumab
. โKeep Calm and Transfuse On
#Blooducation
A 1 day y/o ๐ถ๐ฝneonate, born at 40 weeks, was transferred to our NICU for anemia & hyperbilirubinemia. He is jaundice but has no signs of encephalopathy.๐ฉธThe antibody screen is positive.
๐๐ฝCheck out his peripheral smear below and notice the increased number of nucleated RBCs.
Peripheral smear findings of COVID19 patient. Burst of
#Inflammasomes
leading to CML-like picture. Notice how all leukocytes have toxic cytoplasmic accumulation. They resemble painted warriors coming back from battle. Also
#covicytes
๐งฟ present.
Itโs 5:30 am and Iโm waiting ๐ฅถoutside in line to vote. Proud to be standing among fellow Americans who make this the first priority of their day.
#GoVote
๐๐ซ๐Kissing and hugging?
Check out this ๐ถ๐ง๐ฌperipheral smear below of a 4 y/o girl with EBV and the presence of reactive lymphocytes known as Downey cells which seem to kiss ๐ and hug ๐ซ the red blood cells.
Giving baths while working on a presentation. Iโm sometimes asked, how to balance work & parenting? Not a balance but a ๐ merry go round. Jump on, jump off, while itโs spinning of course. Often, the children & work are riding at the same time! Playground?
#WomenInMedicine
This is AML with T(3:3). Hyperleukocytosis (WBC = 400K, 65% BIG, bulky blasts) presenting with symptoms of leukostasis. Check out the buffy coat ๐ฑand the 1x slide.
1/9: 88 y/o woman with a history of hypothyroidism presents with a 3 day h/o abdominal pain and bloody diarrhea. Rising creatinine. Anemia with fall in platelet count. Peripheral smear shows the following ๐
#TMBlooducation
#pathologytweetorial
This is a 43 y/o patient with ITP status post splenectomy.
โ๏ธCan you guess why he has a thrombocytosis?
๐๐ผCheck out this smear below and noticed the giant platelets and Howell Jolly bodies ๐ถ๐ง
Iโve seen
#hemophagocytosis
in body cavity fluid smears, but never in the peripheral blood. What does this finding suggest if readily present on a peripheral smear? Is HLH a possibility in the right clinical scenario?
This is a target cell ๐ฏotherwise known as a codocyte (red arrow).
They have an increased surface membrane to volume ratio leading to a central darker hemoglobinized region.
โ๏ธWhat conditions can you see them in?
I agree. The lab is in the dungeon (aka Lower Level) of the hospital.
And we are thrilled to be recognized
@DGlaucomflecken
for the work we do.
Meet Ron in the lab who agrees with the importance of a properly labeled specimen ๐๐ผ
๐งฌ๐ฉธ๐งซ๐ฌ๐ฉ๐ฝโ๐ฌ๐งโ๐ฌ๐จ๐ฝโ๐ฌ
stop by for a
#hotcocoa
1/10
A 26-y/o man with HbS disease has recurrent episodes of priapism ๐ฑ HbS is 51%. He has just arrived to the ER with another painful crisis.
Take a look at this peripheral smear, notice the drepanocytes, or sickle-shaped cells in the peripheral smear below ๐๐ฝ
#PathBoards
Today my daughter turned 5. When offered an aisle-long selection of Barbies, she choose one of color. I felt so proud. Of course, I wish the mermaid carried a stethoscope or microscope ๐คฃ, but I donโt think mermaids get too sick.
1/10
These are the lungs of a patient who died while receiving a PLT transfusion. He developed sudden respiratory distress and did not respond to O2 support. Lungs compressed by 3000 mL of transudative pleural fluid. Notice the increased neutrophils
#PathTweetorial
Big, bulky, sticky blasts.
76 y/o presents w SOB and elevated troponins.
๐ฒWBC = 256K with 97% blasts
๐๐ผCheck out the peripheral smear. These blasts can clog up the microvasculature & lead to symptoms of leukostasis. Urgent leukapheresis was iniated as hydroxyurea was started.
Curbside teaching moment in the ๐ฉบ๐ฉธMICU resident training rooms. Called about a patient with decompensated liver cirrhosis presenting with bleeding.
How to use TEG to treat this coaguloapthy?
๐๐ผCheck out TEG6S global hemostasis with lysis results below.
A 54-year-old man with ETOH cirrhosis presents w/severe ascites, jaundice & fever. He is not bleeding. Diagnostic paracentesis is ordered. Labs are drawn. Hb 11.5, PLT 69K, INR 2.3. ๐ฒThe intern asks how much FFP to transfuse. ๐ฃ๏ธYou respond:
#PathTweetorial
#Blooducation
๐ซคOh man.
Kleihauer-Betke test is positive.
Rh- negative mom, Rh-positive baby.
Full term. Healthy with no signs of anemia.
Before administering RhIG letโs think about
what can cause a false positive KB and what further testing should be performed?
#Blooducation
Unfortunately, cells donโt wear a name badge, but use this criteria to identify
#blasts
1.) Am I big?
2.) Do I have a high N/C ratio?
3.) Do I have fine nuclear chromatin?
4.) Do I have a prominent nucleoli?
If yes to all, then Iโm a blast!
This is the pleural fluid smear of a 67-year-old man s/p autologous transplant for Multiple Myeloma who presented with shortness of breath due to a right-sided pleural effusion. ๐๐ผ๐ฌCheck out the atypical plasma cell below. Wright stain.
68 y/o woman presents with worsening shortness of breath and bilateral leg swelling. Since you are the
#LabMedicine
resident covering the Heme Bench, you are called to review a critical smear. Take a look below ๐๐ผ
9 y/o with neuroblastoma presents with fever and cough๐ฎโ๐จ
Influenza A positive.
๐๐ผTake a look at this slide of the peripheral smear below and notice the large, reactive lymphocyte known as an immunoblast classically seen in viral infections.
(Wright stain)
This is a peripheral smear of a patient with iron deficiency anemia. Check out the numerous
#elliptocytes
(orange arrow) also known as โ๏ธ pencil cells. In hereditary elliptocytosis, genetic mutations in RBC membrane cytoskeleton proteins lead to unstable & irreversible changes.
This is a bag of cryoprecipitate (cryo). It is made from the plasma portion of whole blood and contains Factor VIII, VWFactor, fibronectin and FIBRINOGEN.
โ๏ธIt is stored in the blood bank freezer at โค18ยฐC and needs to be thawed before transfused.
FIBRINOGEN, also known as
Critical bleeding is associated with a high mortality rate in patients with trauma.
JAMA Associate Editor
@seymoc
discuses the results of the CRYOSTAT-2 trial with Nicola Curry, MD,
@OUHospitals
, and Ross Davenport, PhD, Centre for Trauma Sciences, UK.
@kathryniveyy
This is what acute leukemia looks like with a WBC count of 350K. Sadly the patient died within 48 hours. This was a recent case that made me ๐ฑ