PMC9108757_01
Morphologic findings in peripheral blood and bone marrow. Peripheral blood smear (A) shows left-shifted neutrophils (green arrow), monocytosis (blue arrow), and coarse basophilic stippling (orange arrow). Bone marrow aspirate shows scattered myeloblasts (red arrow, B), monocytic cells (blue arrow, B), ring sideroblasts (C), nuclear irregularity in erythroids (D), and dysplastic megakaryocytes (E). Clot section shows hypercellularity, atypical megakaryocytes, and left-shifted granulocytic and monocytic cells (F). [Wright-Giemsa stains in images A, B, D, and E (100x objective), iron stain in C (100x objective), and hematoxylin and eosin stain in F (20x objective)].
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The PB smear (Fig. 1A) demonstrated granulocytic leukocytosis (WBC 35 x 109/L) with left-shifted neutrophils, including myelocytes and metamyelocytes [5%, green arrow; mature neutrophils (segmented/banded) 62%] and occasional dysplastic neutrophils, markedly relative and absolute monocytosis (29%, 7 x 109/L, blue arrow), severe anemia (hemoglobin 4.3 g/dL) with occasional coarse basophilic stippling (orange arrow), and mild thrombocytopenia (platelets 146 x 109/L). BM aspirate smear demonstrated left-shifted granulopoiesis with 3% myeloblasts (Fig. 1B, red arrow), scattered atypical/dysplastic neutrophils, increased monocytic cells (10%, blue arrow), dysplastic erythroids with ring sideroblasts (10% of erythroids, Fig. 1C, orange arrow) and nuclear irregularity (Fig. 1D, orange arrow), increased myeloid: erythroid ratio (7.9:1), and dysplastic hypolobated and small megakaryocytes (Fig. 1E, violet arrow). Core biopsy and clot sections (Fig. 1F) showed a hypercellular BM (cellularity ~100%) with increased left-shifted granulocytic and monocytic cells and occasional hypolobated megakaryocytes.
Immunophenotypic findings in bone marrow aspirate by 10-color flow cytometry: There are immunophenotypic aberrancy on CD34(+)/CD117(+) myeloblasts (in red, 0.88% population, aberrantly expressing CD5, CD56, and dimly expressing CD33), increased monocytes [(in blue, 11%, with a nearly uniform expression of CD56 and a high fraction of CD14(+)/CD16(-) classical monocytes (estimated at 96% of total monocytes)], and neutrophils (in green) with abnormal maturation pattern on the CD11b/CD13 plot. The fractions of CD14(+)/CD16(+) intermediate and CD14(-)/CD16(+) non-classical monocytes could not be estimated due to the panel design.
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Flow cytometric analysis on the BM aspirate (Fig. 2) was performed on 10-color BD FACSCanto flow cytometer (Becton Dickinson, San Jose, CA) and analyzed using cluster analysis with Cytopaint Classic Software (Leukobyte, CA).