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Case study (23)- Chronic myelomonocytic leukemia (CMML)with Anemia.

Case study (23)- Chronic myelomonocytic leukemia (CMML)with Anemia.

Case study (23)- Chronic myelomonocytic leukemia (CMML)with Anemia. 

History and clinical signs and symptoms 

A 70-year-old woman was diagnosed with chronic myelomonocytic leukemia 6 months ago and was remitted following the appropriate treatment. 

Now the patient returned for a scheduled assessment. 

Laboratory Investigations 

1. Hematologic findings 

RBC:2.76 X 106/μL (4-5.5 X 106/μL) 
HGB: 77 g/dL (120-174 g/dL) 
HCT: 25.6 % (36-52%)
MCV: 92.8 fL (76–96 fL)
MCH: 28.1 pg (27-32 pg)
MCHC: 303 g/L (300-350 g/L) 
RDWsd:65.1* fL (20-42 fL) 
RDWcv: 20.3 * % (0-16 %) 
WBC: 102.0* X103/ μL (5–10 X 103/ μL) 
Neutrophils: 76.98 * X 103/μL (2-7.5 X 103/μL) 
Lymphocytes: 7.35* X 103/μL (1.08–3.17 X 103/μL) 
Monocytes: 13.88* X 103/μL (0.15-0.7 X 103/μL) 
Eosinophils: 0.10* X 103/μL (0-0.5 X 103/μL) 
Basophils: 3.78* X 103/μL (0-0.15 X 103/μL) 
Neutrophils %: 75.4+ % (40-75 %) 
Lymphocytes %: 7.2 % (14.76-45.4 %)
Monocytes %: 13.6+ % (3-7 %)
Eosinophils %: 0.1 % (0-5 %) 
Basophils %: 3.7++ % (0-1.5 %) 
PLT: 173 X 103/μL (150-400 X 103/μL) 
Warning Flags D, Morphological Flags GL, Interpretive Flags Anemia? Macrocytic PLT ?, Anisocytosis? 


The WBC difference (DIFF) and basophils (BAS) population are not clearly defined. 

The WBC count is markedly elevated. (The flag “*“ means that the measured parameter is out of the linearity range.) 

The WBC populations are convergent. Neutrophils and monocytes of white blood cells overlap. (Flag “D” it is warned that monocytes and neutrophils cannot be clearly distinguished on the scattergram.) 

Flag “G” and “L” indicates the presence of immature neutrophils and atypical lymphocytes, respectively. 

The basophil count and percentage increased significantly. 

The RBC and PLT histograms are clearly separated. The RBC count is lower than normal. The HGB and HCT values 

are also low and support severe anemia (see also the interpretative flag “anemia”). 

The RBC population is heterogeneous (see RDWcv and the interpretative flag “anisocytosis”). 

The PLT count is within the normal reference range. However, the PLT volume (MPV) is higher than normal and increases the presence of macrocytic PLTs. 

warnings and morphological flags, visual evaluation of peripheral blood smears is strongly recommended

Peripheral blood smear 

In line with the diagnosis of chronic myeloid leukemia, the atypical myeloid cells including blasts, pro-myelocytes, myelocytes, metamyelocytes, and band forms of neutrophils are present. 

A few normoblasts (erythroblast/NRBCs)* can also be observed. Macro-thrombocytes are also noted in the peripheral blood smear. (Basophil percentage is 1% while the lymphocytes percentage is 10.7% according to the manual count). 

* NOTE: During the measurement, nucleated red blood cells are resistant to the lysis process. Therefore they are classified falsely into the WBC population. 

This may increase the detected WBC count. WBC may be even lower than that provided. Because of their similar size and structure, NRBCs are counted mainly to the lymphocyte population. Thus, the analyzer’s lymphocyte count is falsely elevated. 

The HumaCount 5L system cannot reliably identify blasts, immature, and abnormal cells. 

This also demonstrates that automated results are for rapid screening purposes only. The importance of evaluating peripheral blood smears under a microscope with abnormal results, especially in case of warning flags is high. 

2. Other laboratory findings 

- Currently, there are no other significant laboratory or physical findings. 


Anemia due to chronic myelomonocytic leukemia relapsed

Disease course 

- To correct the anemia, the patient received an RBC blood transfusion. The next course of chemotherapy was scheduled.