A 69-year-old woman was admitted with rapidly declining hypotension and respiratory failure requiring intubation. Complete blood count was reported with a leukocyte count of 133 × 109/L, although this was flagged as the impedance volume histogram of the leukocyte population produced by the cell counter had several abnormal peaks. Blood film showed a leukoerythroblastosis with numerous nucleated red blood cells (red arrows) and megakaryocytic fragments (green arrows). These cells were incorrectly identified as leukocytes by the cell counter, and manual examination of the peripheral smear revealed the leukocyte count was actually 41 × 109/L, although markedly left-shifted. The patient unfortunately died of cardiogenic shock and sepsis after care was withdrawn.
Value of the peripheral blood film: megakaryocytic fragments misidentified by automated counter
Image credits: ASH image bank
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