QSP Newsletter

QSP Newsletter 48 - Monoblast, Promonocyte, Sideroblastic Anemia 

July 2024

Monthly Digital Case Study
Quiz
(PDF for print)

Monthly Digital Case Study (QSP Slide 3, July 2024)

FBC Results

WBC 32.5* (10^3/mm3)Large Platelets 2
RBC 3.55 (10^6/mm3)Neutrophils 61.1%
HGB 10.6 (g/dL)Lymphocytes 7.6%
HCT 30.8 (%)Monocytes -%
MCV 86.8 (fL)Eosinophils 0.8%
MCH 30.0 (pg)Blasts 17.6%
MCHC 34.5 (g/dL)Myelocytes 7.6%
PLT 88* (10^3/mm3)Metamyelocytes 5.3%
 Erythroblasts 3

Clinical Details

Male age 63, Emergency Unit

Slide Information

Thrombocytopenia.
Leukocytosis.
Neutrophilia.
Monocytosis: Monocytes/promonocytes/monoblasts?
Search for acute leukemia.

Neutrophils sometimes degranulated.
Myelemia+erythroblastosis.
Promonocytes(++).
Presence of macroplatelets.
For the attention of the expert: AML (4/5)?

 

In the context of AML with a monocytic component, should promonocytes always be classified with (mono) blasts: WHO criteria.
Blastosis estimated in this case at 5 G/L (15% of leukocytes).
Expert comment: Appearence compatible with (monoblastic) AML5

Monoblast or Promonocyte?

In the paper ‘Morphological evaluation of monocytes and their precursors' published 2009 in the journal Hematologica, a guide to identify the monocyte subtypes was presented. The article separated monocyte into 4 types, Monoblast (the precursor cell), Promonocyte, Immature Monocyte and Monocyte, with the following characteristics.

CellNuclear ShapeChromatinCytoplasmComments
MonoblastRound/OvalDelicate/ lace like. Nucleolus prominentBasophilic. Rare azurophilic granuleLarge 20 – 40 um
PromonocyteConvoluted/indentedDelicate/ lace like. Nucleolus prominentVariably basophilic. Variable azurophilic granulesExcept for nuclear shape, very similar to monoblast
Immature MonocyteConvoluted/indentedMore condensed, Rare nucleolusLess basophilic than promonocyte or blast but more basophilic than mature monocyteResemble monocyte but less mature and smaller
MonocyteLobulated/IndentedCondensed no visible nucleolusGray. Occasional azurophilic granules. Occasional vacuoleLarge 20 – 25 um

Using the above table, we can identify the following cells in the slide.

Monoblast

Promonocyte

Monocyte (different slide)

It is important to be able to differentiate between Promonocytes and immature/mature monocytes as in the WHO classification, Promonocytes are included with Monoblasts.

 

WHO Classification of Acute Myelomonocytic and Acute Monocytic Leukemia

Acute Myelomonocytic Leukemia≥ 20% monocytes and their precursors
Acute Monocytic Leukemia≥ 80% monocytes and/or their precursors (monoblasts and/or promonocytes)

July Slides

Microcytic anemia

Anemia, thrombocytopenia

See monthly case study above.

Evolving CLL

Neutrophilia.
Microcytic anisocytosis(+++).
Poikilocytosis(++).
Ovalocytes/elliptocytes(++).
Dacryocytes(++).
RBC fragments.
Hypochromia(++).

Expert comments: In favor of MDS. Sideroblastic anemia?

Neutrophilia, thrombocytosis, discrete myelemia, discreet erythrobalstosis

 

Cell Quiz

Slide 5 is querying sideroblastic anemia. Is the cell above a ring Sideroblast and if not why not?

 

The answer will be displayed in the next QSP Newsletter and on our social media (LinkedIn / Facebook / X).

Last Month’s Quiz Answer

Name this cell.

The Answer:

A normal Eosinophil

Bibliography

Morphological evaluation of monocytes and their precursors

Haematologica. 2009 Jul; 94(7): 994–997.

Important Announcement Regarding QSP Newsletter

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As some of you may already know, Quality Slide Program (QSP) is scheduled to be discontinued at the end of this year. Therefore, this month’s issue will be the final edition. Starting in October, we will introduce a new name for the newsletter and continue to provide educational content focused on cell morphology. We plan to incorporate feedback from our subscribers’ surveys into the content.

We would like to express our heartfelt gratitude to all of you who have been loyal readers of the QSP Newsletter over the past four years. We remain committed to delivering valuable information in the future.

QSP Newsletter Editorials

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All the QSP Newsletters published before are available here.

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