You are on page 1of 34

University

of Illinois
College of Medicine
at
Urbana-Champaign

!"#$-!"#$

Pathology Laboratory Manual

2013-2014 Pathology Laboratory Schedule


Day
Fall
Tue
Wed

Date
2013
10/15
10/16

Tue
Wed

10/29
10/30

Tue
Wed

12/10
12/11

Tue
Wed

12/17
12/18

Spring
Tue
Thu

2014
1/28
1/30

Tue
Wed

2/11
2/12

Time

Path lab/Prep

Instructor

Location

1-4pm
10.30am12.30pm
1-4pm
10.30am12.30pm
1-4pm
1.00am3.00pm
1-4pm
10.30am12.30pm

Lab prep (optional)


Microscope Intro/
Cardiovascular
Lab prep (optional)
Pulmonary lab

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

Lab prep (optional)


Hematology lab

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

Lab prep (optional)


Blood smear lab

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

1-4pm
10.30am12.30pm
1-5pm
10.30am12.30pm

Lab prep (optional)


GU/ Reproductive
lab
Lab prep (optional)
GI lab

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

Students
Nandkumar

Library 2B & 2C MSB


256 MSB

UICOM Pathology Discipline Coordinator


Dr. Steve Nandkumar
249 Medical Sciences Bldg
506 South Mathews Ave
Urbana, IL 61801
217-244-4841
snandkum@illinois.edu

Students should prepare for the cases before the laboratory


Students may have access to the classroom (256 MSB) whenever it is not scheduled for use. Please check for
room availability with Rita Knight (rlknight@illinois.edu) in the Deans office.
Laboratory prep times have been reserved in Library rooms 2B and 2C. These dates/times are noted in the
Pathology laboratory schedule.

Pathology Laboratory Sessions


Participation in Pathology labs is Mandatory
Pathology laboratory sessions are held in the Medical Sciences Building (MSB). Limited street parking
is available at MSB. It is recommended that students carpool. Parking in reserved spaces is not allowable.
Most of the Pathology labs require viewing of microscope slides that contain tissues from human cases.
The Pathology slide collections and student microscopes are in the cabinet in room 256 MSB. There are 2 keys
to this cabinet available in 1) The MSB library (front desk) and 2) 256 MSB blue key locker attached to the
white refrigerator handle. The combination is 829.
Any one key will open the cabinet.
These microscope slides come from real patient cases. They cannot be replaced. Please handle these slides
with care.
Each student enrolled in Pathology is given access to a web-based lab manual at the beginning of the
course. This manual contains information pertaining to the course such as case studies for each lab and
instructions for use of the video microscope. The lab manual is available at M2 path. web site under manuals.
To assist in preparing for labs you may use your own computer to access the online Cell & Tissue
Biology Atlas. It may be helpful to have a microscope with the Pathology slide in view adjacent to the computer
with the normal Cell & Tissue Biology image in view. In preparing for the cases, each student should review all
slides in preparation for the laboratory. After finding the representative microscopic field(s) of interest, you may
want to make a small mark with a marker on the slide near where the field is located (there are markers in the
cabinet for this purpose). Please make a note to yourself of the number of the slide box from which the slide
came.
During the labs, you will be using a video microscope. This is a microscope equipped with a camera and
projector to show the microscope slides. Instructions for operation of this equipment are in your Pathology lab
manual. A member of your student group will find the representative field(s) or cell(s) on the microscope slide
and project the image for the class to see/ discuss.
The instructor will assign students (2 per case) to present the cases. In order for the Pathology labs to be
most meaningful for all class members, it is imperative that each student participate fully in the presentation of
their case(s). Each group member should have a specific role. For example, one student might operate the
microscope and be prepared to find diagnostic areas; another student might point out areas of interest in the
tissues and discuss diagnostic criteria; another should be prepared to discuss epidemiology, risk factors,
prognosis and the like. The rest of the class should be prepared to discuss each case.
For any additional information, please contact the Lab Coordinator:
Ms. Crystal Hults
379 MSB
300-2829
chults@illinois.edu

Basic Instructions for Using a Light Microscope


(Refer to the microscope diagram on next page)

Carry the microscope using both hands, one hand carrying the arm and one hand holding the base. Remove the
dust cover. Using lens paper, remove any dust from the eyepieces, stage, light source, or condenser.

Adjust the height of the condenser lens using the condenser lens focus knob located below the stage. The
condenser lens needs to be positioned very close to the microscope slide.

Plug in and turn on the light source (this differs with different brands of microscopes). Begin with the light at a
low setting (e.g.; 1-3). Rotate the objective nosepiece so that the 10x objective is just to the side of the viewing
position.

Position the glass microscope slide with the side to be viewed up and place it into the stage clips.

The stage control knobs are found underneath and to the side of the stage. Use these control knobs to move the
microscope slide horizontally and vertically. Position the slide so that the desired area is in the viewing area.

Rotate the objective into viewing position. Usually, begin with the 10x objective.

The iris diaphragm is located below the stage. It can be opened/ closed with the diaphragm lever. To maintain
image resolution, it usually should be at least 2/3 open.

The dial on the light source may be used to adjust the light intensity. Generally, less light is needed for low power
magnification. The iris may need to be opened more and/or the light intensity increased when going to higher
magnification.

The focus adjustment knobs are below the stage at the base of the arm. The course adjustment knob is the larger
outer knob. The fine adjustment is the inner knob. Using 10x or 40x objectives, course adjustment is used to bring
the image into approximate focus. Then slight adjustments are made with the fine adjustment.

If additional slides are to be viewed, rotate the objective aside and position the new slide in the viewing area.
Rotate the objective into viewing position. Only minor adjustments in focus should be needed.

For viewing bacteria or blood smears, it is necessary to go to 100x (oil immersion) magnification. Be sure the
microscopic field is as focused as possible on lower magnifications. Turn the objective nosepiece to the side. Add
a small drop of immersion oil to the top of the microscope slide over the desired field. Taking care not to bring the
40x objective into oil, rotate the nosepiece so that the 100x objective is in viewing position. It should be in contact
with the drop of oil. [For viewing bacteria, focus the microscope slide with 10x, add the drop of oil and go
directly to 100x.]
With the 100x objective in place, focusing should be performed only with the fine adjustment knob.

After the last slide is viewed, turn the objective aside. Remove the slide.

Clean all objectives, the stage and condenser with lens paper. Rotate the lowest power objective into viewing
position.

Unplug the microscope by pulling on the plug, not the cord.

Wrap the cord around the microscope. Place the dust cover on the microscope for storage.

Operation of the Olympus CX41 video microscope and ASK Proxima C420 Projector
1. The video microscope cart should be positioned approximately 10 feet from the screen. Using the
electric cord on the cart, plug it into a functioning electric outlet. Remove the dust covers from the
microscope and projector.
2. Open the cabinet door on the AV cart. Turn on the power strip. The microscope, camera power supply
and RGB converter are plugged into the power strip. The switches for this equipment should be left in
the off position.

3. With the 4x objective in position, place the desired slide on the microscope. Using normal microscopic
techniques; focus the image in the microscope on low power (4x or 10x) [see handout Basic
Instructions for Using a Light Microscope]. The video microscope has been installed with light
intensity in the mid-range (#4 on the rheostat, right hand side of the scope). Only slight adjustments in
light intensity are necessary. Contrast may be adjusted with the iris diaphragm of the condenser below
the stage.
4. Remove lens cap from the projector. Push on the power button to the projector. It is the labeled
button on top of the projector in the rear left comer. It takes approximately 17 seconds for the
projector to warm up and the image to appear on the screen. If the projector is positioned differently
than 10 feet from the screen, there is a ring around the projector lens that may be used for focusing.

5. As desired bring higher power objectives into position. Focus the image in the microscope first
before making adjustments to the projected image. Do not get any oil on the 40x objective. Immersion
oil must be used with the 100x objective. Immersion oil and lens paper are available on the cart or in the
microscope cabinet in the Pathology classroom.
6. When you are finished with a slide, please clean it thoroughly with lens paper before returning it to
appropriate storage. When you are finished with the microscope, use lens paper to remove all oil and
dust from objectives, eyepieces, and the stage.
7. When the video microscope and projector are no longer needed for class, first turn off the projector by
pushing the power button twice within 3 seconds. Leave the power strip on to allow the projector fan to
run 5-10 minutes for cooling purposes. The lamp turns off and the LED blinds green for 1 minute while
the fans continue to cool the lamp. When the lamp has cooled the LED lights green and fans stop.
Replace the lens cap on the projector.
8. Leave the microscope, camera power supply and RGB convertor turned on. Turn off the power strip.

9. Unplug the electric cord to the AV cart. Replace the dust covers on the microscope and projector. Return
the cart/equipment to storage.
10. Lamp replacement: A replacement lamp for the microscope is stored in the cabinet of the AV cart.
Instructions for lamp replacement are found on page 6 of the Olympus CX31 manual. Notify the Lab
Coordinator if this lamp is used. A replacement lamp for the projector is stored in the office of the
Audiovisual Specialist (IT Dept, 263 MSB). Instructions for lamp replacement are on page 42 of the
Proxima C420 manual.
11. Hooking up a laptop: while both the laptop and projector are in the off state, attach the supplied VGA
cable to the external monitor jack on the back of the laptop, and to the computer 1 jack on the projector.
Power up the laptop, then the projector. Use the video and computer buttons on top of the projector
to toggle between the 2 (laptop and scope).
The video microscope and projector usually will be stored in a secure location. Usually the equipment will be
setup by the Lab Coordinator.
Complete instruction manuals for all equipment components are found in the binder on the Pathology video
microscope cart.

Pathology Computer Resources


The Atlas of Pathology provides labeled images of normal and abnormal tissue with accompanying legends. It
can be found at https://www.med.illinois.edu/m2/pathology/PathAtlasf/titlepage.html.
By using the above program, it is understood that you may not further copy the program or the data. These are
property of the GRIPE Consortium and licensed for student use only to UICOM-UC students.

Cell and Tissue Biology Atlas


The UICOM-UC Cell & Tissue Biology (CTB) Atlas is available as a reference while viewing Pathology slides.
The CTB Atlas can be found at https://histo.life.illinois.edu/histo/atlas/index.php.

Table of reference intervals


Specimen

Test

S
B
P
S/P
S/P
S/P
S/P
P
S/P

Albumin
Base excess
Bicarbonate
Bilirubin, conjugated
Bilirubin, total
Calcium, total
CO2, content, venous
Chloride
Cholesterol (NCEP

Reference interval
(conventional units)
3.8-5.0
-3.3 to +2.3
21-28
<0.3
0.1-1.2
9.2-11.0
24-30
95-103
140-200

g/Dl
mEq/L
mEq/L
mg/Dl
mg/Dl
mg/Dl
mEq/L
mEq/L
mg/Dl

Conversion
factor
(multiply by)
10
1
1
17.1
17.1
0.25
1
1
0.026

Reference interval (SI units)


38-50
-3.3 to +2.3
21-28
<5
2-21
2.3-2.7
24-30
95-103
3.6-5.2

g/L
mmol/L
mmol/L
mol/L
mol/L
mmol/L
mmol/L
mmol/L
mmol/L

27.6
88.4
0.0167
1
1
0.01
2.265
0.0556
0.01
0.01
0.01
10
0.179
0.179
0.111
0.048
1
0.5
0.0155
0.01
1
1
0.133
1
0.323
0.133
106
1
10
106
106
0.073
1
13
0.0113
0.357
0.05948
0.74
106
0.153

138-635
53-106
1.4-2.3
15-200
12-150
2.00-9.00
>5.0
3.9-6.1
0.6-2.7
0.415-0.504
0.359-0.446
120-180
10.7-26.9
44.8-71.6
0.6-2.2
<2.41
0.5-1.4
0.65-1.05
27.5-33.2
33.4-35.5
80-96
280-295
4.7-5.3
7.38-7.44
0.74-1.52
12.7-13.3
150-400
3.8-5.0
60-78
4.5-5.9
4.5-5.1
1.1-2.2
136-142
12-30
0.11-2.15
2.9-8.2
0.16-0.51
118-701
4.4-11.0
7.7-23.0

nmol/L
mol/L
Ml/s
g/L
g/L
g/L
nmol/L
mmol/L
g/L
Vol fraction
Vol fraction
g/L
mol/L
mol/L
mmol/L
mol/L
mmol/L
mmol/L
pg
Concentration fract.
fL
mmol/kg
kPa

recommendation)

P
S/P
S/P
S/P
P
S/P
S/P
S
B
B
B
S/P
S/P
S/P
B
S/P
S/P
B
B
B
S/P
B
B
S/P
B
B
P
S
B
B
S/P
P
S
S/P
S/P
S/P
S
B
S

Cortisol (a.m.)
Creatinine
Creatinine clearance
Ferritin (men)
Ferritin (women)
Fibrinogen
Folate
Glucose, fasting
Haptoglobin
Hematocrit (men)
Hematocrit (women)
Hemoglobin
Iron, total
Iron binding capacity
Lactic acid, venous (lactate)
Lead
Lithium, therapeutic
Magnesium
MCH (RBC index)
MCHC (RBC index)
MCV (RBC index)
Osmolality
Pco2 (arterial)
Ph (arterial)
Phosphate (as P)
Po2 (arterial)
Platelet count
Potassium
Protein, total
RBC count (men)
RBC count (women)
Salicylate, therapeutic
Sodium
Thyroxine, free
Triglyceride (as triolein)
Urea nitrogen (BUN)
Uric acid (urate)
Vitamin B12
WBC count
Zinc

5-23
0.6-1.2
87-139
15-200
12-150
200-400
>2.3
70-110
60-270
41.5-50.4
35.9-44.6
12-18
60-150
250-400
5-20
<50
1.5-1.4
1.3-2.1
27.5-33.2
33.4-35.5
80-96
280-295
35-40
7.38-7.44
2.3-4.7
95-100
150-400
3.8-5.0
6.0-7.9
4.5-5.9
4.5-5.1
15-30
136-142
0.9-2.3
10-190
8-23
2.7-8.5
160-950
4.4-11.0
50-150

g/Dl
Mg/Dl
Ml/min/1.74 M2
Mg/Ml
Ng/Ml
Mg/Dl
Ng/Ml
Mg/Dl
Mg/Dl
%
%
g/Dl
g/Dl
g/Dl
mg/Dl
g/Dl
mEq/L
mEq/L
pg
%
m3
mOsm/kg
mm Hg
mg/Dl
mm Hg
103/mm3
mEq/L
g/Dl
106/mm3
106/mm3
mg/Dl
mEq/L
ng/Dl
mg/Dl
mg/Dl
mg/Dl
p/Ml
103/mm3
g/Dl

mmol/L
kPa
109/L
mmol/L
g/L
1012/L
1012/L
mmol/L
mmol/L
mol/L
mmol/L
mmol/L
mmol/L
mol/L
109/L
mol/L

Specimens: B, whole blood; P, plasma; S, serum


Reference intervals depend on test method and the demographics of the normal population used.
Source: Henry JB, ed. Clinical Diagnosis and Management by Laboratory Methods. 19th ed. Philadelphia, PA: WB Saunders Co; 1996.

CARDIOVASCULAR SYSTEM LABORATORY


Case MA 50-79
A 56-year-old Caucasian male was admitted with chronic fever of unknown etiology (FUO). History revealed
that the patient had a fever for the past 5 weeks. There was associated weakness and fatigue. There was no
hemoptysis, hematemesis, chest pain, weight loss, dyspnea, or fainting spells. Family history was noncontributory. Personal habits: the patient denied smoking or alcohol consumption.
Examination: The patient was alert and oriented but appeared pale. Pulse: 130/min
and regular; Temp: 102 F; B.P.: 120/80 mm Hg. Resp. rate: 24/min.
Heart: a faint systolic murmur was heard. This appeared to change over the next few days.
RS, AS, and CNS: noncontributory
Laboratory investigations
Hb: 8.2gm%
Hct: 25 %
TC: 13,100/cmm Urine: RBCs +++
BUN: 50mg%
Serum creatinine: 2.6 mg%

Blood Culture
Gram negative coccobacilli

Chest x-ray
Bilataeral pleural effusions
Changes of moderate congestion
The patient was treated with antibiotics and antipyretics. He developed dyspnea and personality
changes five days after admission and died following a "sudden" cardiac arrest.
A-26-77 (1 & 21)
78-year-old male, status post bowel resection for Ca colon develops post- operative sepsis, jaundice, and
congestive heart failure. His condition deteriorates rapidly and he expires following renal shut down and
cardiac failure. Sections of heart from autopsy.
76-A-41 (11 & 12)
A 52-year-old female with a history of respiratory tract infection of 3 weeks duration. Fever, breathlessness,
and dull chest pain progress and she expires despite Rx. Sections of the heart.
A-53-80 (3 & 10)
A 76-year-old with chronic organic brain syndrome develops a progressive refractory congestive
heart failure. Sections of heart from autopsy.
SB 1705-78 (2 & 4)
A 70-year-old female is admitted with complaints of throbbing headache, visual disturbances, and fever. A
diagnostic biopsy is done.

HINTS TO THE CARDIOVASCULAR LABORATORY CASES

MA-50-79 (5 slides)
From the case history of FUO for several weeks, some kind of infection should be suspected. Personality
changes and hematuria indicate the involvement of the brain and kidney. The patient died of cardiac arrest
despite intensive treatment with antibiotics. Such arrest indicates the likelihood of a cardiac origin. Tissue
sections from the heart and other organs (such as spleen, kidney, and brain are provided to study. Please pay
attention to the infectious foci in the different tissues/organs. In the heart, concentrate on the valve. Please
review the term vegetation.
Your diagnosis is ____________________________
A-26-77 (1 & 21)
From the case history it is known that the patient died of heart failure. Please pay attention to the following:
myocardiocyte changes, changes in the coronary arteries, inflammatory response, and other abnormalities.
Your diagnosis is _____________________________
BH 76-A-41
Analyze the slides using the same format as used in the above 2 cases. You may find that you have stomach or
esophagus sections in the slides. Concentrate on the cardiac sections.
Your diagnosis is _____________________________
A-53-80 (3 & 10)
Find the significance of the Congo Red stain on section 10 and visualize the specimen using the pair of
polarizing filter lenses.
Your diagnosis is _____________________________
SB 1705-78 (2 & 4)
This should be an easy one.
Your diagnosis is _____________________________

PULMONARY LABORATORY
CASE MA 59-79
HISTORY:

A 58-year-old male is admitted to the hospital with complaints of weakness, confusion, difficulty in walking,
fever, edema of several days duration, and polyuria.
The B.P. is 160/100 mm Hg and the patient is admitted for evaluation.
CHEST X-RAY:
A nodular density in the left lower lung field and changes suggestive of chronic obstructive pulmonary
disease are noted.
LAB TESTS:
Blood glucose
Urinary
Urinary
Urine
CBC
Hb
WBC
Platelets

510 mg%
17-Ketosteroids
17-Ketogenic steroids
17-0H Corticosteroids

74 mg/24 hours
176 mg/24 hours
103 mg/24 hours

9.l gm%
3700/cmm
decreased from 105000 to 9000/cmm

Liver Scan
Hepatomegaly has diminished "uptake" in left lobe
Cat Scan
Bilateral adrenal enlargement
Blood Culture
Negative (no organism grown in 9 days)
A needle aspiration biopsy of the left lung "density" is done. The pathology report is noncontributory
(inflammatory cells seen). The patient develops pneumothorax, diffuse lung infiltrates and shock, and
expires six weeks after admission.

HINTS FOR THE PULMONARY LABORATORY


There are 5 slides containing 12 sections.
It is a relatively complex case. Please study the case history carefully. Locate the normal values for the lab tests
given and find the significance of all given clinical symptoms and physical findings before you start to study the
slides.
From the case history, you may realize that this is a multi-systemic problem. You have:
Lung
Liver
Kidney
Thyroid
Pituitary
Prostate

Lymph node
Heart
Brain
Stomach/ esophagus
Adrenal
Bone marrow

Please look at these tissues under low power and identify the tissue first. Then concentrate on the strange
looking dark cellular areas and areas of bluish branching/ round structures. Try to answer the following
questions:
1. What type of abnormal cells do you see in the lung, lymph node, and liver?
2. What type of organism do you see in the inflammatory foci of various organs?
3. Why does this organism associate with the abnormal lymphocytic looking small cells?
4. What are paraneoplastic syndromes?
5. What is Crookes hyaline degeneration?
6. Your diagnosis for this case is/are:____________________________________________________

HEMATOLOGY LABORATORY CASE HISTORIES

The purpose of this laboratory is to provide hands on experience with evaluation of peripheral blood smears.
You will also be expected to correlate what you see with laboratory data and clinical history. You will have
peripheral blood smears to study prior to this session. The class will be divided into groups, each having the
responsibility for presenting one case. First discuss the laboratory data and clinical information. Next describe
and show the findings using the microscope/monitor. Lastly, give your diagnosis, or at least differential
diagnosis, and other tests that would be helpful.
Evaluation of peripheral blood slides in a systematic manner helps in picking out the important points. Hints
include: (1) be sure the cover- slipped side of the smear is facing the objective; (2) first focus using the low
power objective, then switch to the oil objective; (3) choose a well-stained area of the slide to view the smear.
The feathered edge where the RBCs are just beginning to touch and are not overlapping is best; (4) note any
abnormalities (cytoplasmic, nuclear) of the leukocytes; do a 100-cell differential if you have time; (5) evaluate
the RBCs for anisocytosis, poikilocytosis, hypochromia, polychromasia, and inclusions.
For the bone marrow biopsy: (1) first on low power and later on high dry, examine the bone marrow biopsy for
the overall cellularity, the distribution of myeloid and erythroid cells, and the presence or absence of foreign
cells, fibrosis, granulomas, etc.; (2) bone marrow smears are not available for review; however, see if you can
identify myeloid, erythroid, and megakaryocytic cells in the bone marrow sections. Is there maturation? DO
NOT use the oil objective when looking at the bone marrow biopsy.
For the lymph nodes: (1) under low power look to see if the normal architecture is intact, i.e. capsule, sinuses,
germinal centers, interfollicular areas; (2) under higher power look at the abnormal areas and determine why
they are abnormal; (3) DO NOT use the oil objective when looking at lymph nodes. A section of a normal
lymph node is included in your slide set. Compare this with the pathologic lymph node sections. Describe
what you see.

Normal Adult Reference Ranges


WBC

4.5 11.0 x 103/L

RBC

MCV

4.2 5.9 x 106/L (M)


3.8 5.4 x 106/L (F)
13 17 g/dL (M)
12 15 g/dL (F)
40 52% (M)
36 46% (F)
80 100 fL

MCH

27 34 pg

MCHC

32 36 g/dL

Plt

150 400 x 103/L

RDW

12 15%

Hb
Hct

Peripheral blood
PMN
Bands
Lymphocytes
Monocytes
Eosinophils
Basophils
Bone marrow:
Cellularity (%)
Megakaryocytes
Myeloid erythroid
Myeloblasts
Promyelocytes
Myelocytes
Metamyelocytes
Bands
Segmented neutrophils
Eosinophils
Basophils
Nucleated RBCs
Lymphocytes
Plasma cells
Monocytes

WBC differential (%)


36 66%
5 11%
13 43%
2 11%
0 7.5%
0 2%

Absolute Count (x 103/L)


1.6 6.9
01
1.2 3.9
0.1 0.8
0 0.6
0 0.19

estimated as 100-age (in years)


12 25/mm2
2 4.1
0.2 1.5%
2.1 4.1%
0.2 1.3%
9.6 24.6%
9.5 15.3%
6 12%
1.2 5.3%
0 0.2%
18.4 33.8%
11 23%
0.4 3.9%
0 0.8%

HEMATOLOGY LABORATORY
Case 1:
A 72-year-old asymptomatic man saw his physician for a routine checkup. A peripheral blood smear is
available for review.
CBC results:
WBC
RBC
Hb
Hct
MCV
MCH
MCHC
Plt

62.3
3.17
9.8
30.1
95
30.9
32.6
548

Questions:
1. Describe what you see on the slide. Focus on the white blood cells.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?
Case 2:
A 64-year-old man presented to his physician with gradual onset of weakness and lethargy. Physical exam was
unremarkable. A peripheral blood smear is available for review.
CBC results:
WBC
RBC
Hb
Hct
MCV
MCH
MCHC
Plt

5.3
2.05
7.7
21.5
104.9
37.6
35.8
20

Questions:
1. Describe what you see on the slide. Focus on the white blood cell types and cytoplasmic inclusions. Is
the absolute neutrophil count increased, normal, or decreased?
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 3:
A 49-year-old woman saw her physician because of upper abdominal fullness. Physical exam revealed
splenomegaly. (2 slides for review one peripheral blood and one bone marrow biopsy).
CBC results:
WBC
RBC
Hb
Hct
MCV
MCH
MCHC
RDW
Plt

232.0
3.73
11.5
34.3
92.2
30.8
33.4
17.2
604

Questions:
1. Describe what you see on the slides. On the blood smear identify the white blood cell types. On the bone
marrow biopsy, focus on the cellularity and cell types.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 4:
An 87-year-old woman saw her physician for a slowly enlarging sternal mass. A chest radiograph revealed a
lytic lesion expanding her sternum. Following surgical removal, a 948-gram mass measuring 13.5 x 12.5 x 12
cm was received in pathology. A section of this tumor is available for review.
Questions:
1. Describe what you see on the slide. What is the major cell type?
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 5:
A 24-year-old woman was seen by her physician with night sweats and fever. A CT scan revealed mediastinal
lymphadenopathy. A mediastinoscopy was performed and a lymph node was removed. One slide of the node is
available for review.
Questions:
1. Describe what you see on the slide. Focus on the lymph node architecture, and the cellular and noncellular components.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 6:
An 84-year-old woman presented to her physician with a painless left groin mass. An open biopsy was
performed and a 2-cm lymph node was removed. One slide of the node is available for review.
Questions:
1. Describe what you see on the lymph node slide. Focus on the architecture of the lymph node at low
power and cellular components at high power.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 7:
A 59-year-old woman on routine physical exam had a palpable left cervical and groin nodes which had been
increasing in size over the prior 3 months. Radiographs also revealed mediastinal adenopathy. A lymph node
biopsy was obtained. One slide of the node is available for review.
Questions:
1. Describe what you see on the slide. Focus on the lymph node architecture and the cellular component.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

Case 8:
A 20-year-old woman was seen by her physician for a persistent cough. A chest radiograph revealed hilar
adenopathy. A lymph node measuring 1.8 x 1.2 x 1.0 was obtained by mediastinoscopy. One slide of the node is
available for review.
Questions:
1. Describe what you see on the slide. Focus on the lymph node architecture and the cellular component.
2. What is your differential diagnosis?
3. What other information, tests, etc., would be helpful?

BLOOD SMEAR LABORATORY CASE HISTORIES


The purpose of this laboratory is to provide hands on experience with evaluation of peripheral blood smears.
You will also be expected to correlate what you see with laboratory data and clinical history. You will have
peripheral blood smears to study prior to this session. The class will be divided into groups, each having the
responsibility for presenting one case.
Evaluation of peripheral blood slides in a systematic manner helps in picking out the important points. Hints
include: (1) be sure the cover-slipped side of the smear is facing the objective; (2) first focus using the low
power objective, then switch to the oil objective; (3) choose a well-stained area of the slide to view the smear.
The feathered edge where the RBCs are just beginning to touch and are not overlapping is best; (4) note any
abnormalities (cytoplasmic, nuclear) of the leukocytes; do a 100-cell differential if you have time; (5) evaluate
the RBCs for anisocytosis, poikilocytosis, hypochromia, polychromasia, and inclusions. A peripheral blood
smear labeled Normal is present in your slide set for comparison. In some cases you may want to calculate the
absolute count of the white blood cells.
Remember that the absolute values for the different leukocytes, as well as the differential, can be of value in
making a diagnosis.
3

WBC

4.5-11.0 x 10 /L

RBC

4.2-5.9 x 106/L (M)


3.8-5.4 x 106/L (F)
13-17 g/dL (M)
12-15 g/dL (F)
40-52% (M)
36-46% (F)
80-100 fL
27-34 pg
32-36 g/dL
150-400 x 103/L
12-15%

Hb
Hct
MCV
MCH
MCHC
Plt
RDW

Peripheral Blood
PMN
Bands
Lymphocytes
Monocytes
Eosinophils
Basophils

Normal Adult Reference Ranges


Ferritin 20-250 ug/L (M)
10-120 ug/L (F)
Iron 65-175 ug/dL (M)
50-170 ug/dL (F)
TIBC 250-450 ug/dL
% Sat 20-50 (M)
15-50 (F)
Bone marrow M:E 2-4:1
Reticulocyte count 0.5-1.5%
Corrected reticulocyte count 0.5-1.5%
Absolute reticulocyte count 24-84 x 103/L
WBC differential (%)
36-66%
5-11%
13-43%
2-11%
0-7.5%
0-2%

Absolute Count (x 103/L)


1.6-6.9
0-1
1.2-3.9
0.1-0.8
0-0.6
0.019

BLOOD SMEAR TERMINOLOGY


Anisocytosis variation in red blood ceH size
Poikilocytosis variation in red blood ceU shape
Polychromasia a polychromatophilic non-nucleated red blood cell, when stained with Romanowsky stain is
slightly larger than a mature red cell, and lacks central pallor. These cells are also known as shift cells. They
stain as reticulocytes by using supravital stains due to diffuse residual ribosomal RNA.
Basiphilic stippling fine, medium, or coarse granules uniformly distributed throughout red blood cells stained
with Romanowsky stain. This is due to aggregated ribosomal RNA. Fine stippling is commonly seen in
polychromatophilic red blood cells. Medium and coarse stippling is associated with pathological conditions
such as thalassemias, hemoglobinopathies, sideroblastic anemias, heavy metal poisoning, and pyrimidine-5nucleotidase deficiency.
Howell-Jolly body single or multiple, almost perfectly round, purple nuclear fragments approximately 0.5 m
in diameter; seen within non-nucleated red cells and at times within the cytoplasm of nucleated red cells.
Hypochromia identified morphologically by the expansion of the central zone of pallor to more than one-third
(more than 3 m in diameter) of the red blood cell.
Toxic granulation large, purple or dark blue, azurophilic granules resembling the primary granules of
promyelocytes, unevenly spread in the cytoplasm of neutrophils, bands, and metamyelocytes. These are
associated with severe infection, chemical poisoning, and other toxic states.
Doble body single or multiple, blue, grayish blue, or greenish inclusions of variable size (0.1 to 0.2 m) and
shape (round, elongated, or triangular) in the cytoplasm of neutrophils, bands, and metamyelocytes. Composed
of ribosomal RNA; frequently associated with burns, infections, surgery, and pregnancy.
Atypical lymphocyte (variant lymphocyte, reactive lymphocyte) lymphocytes that show variability in cellular
size and shape as well as nuclear size, shape, and chromatin pattern. Commonly associated with viral illnesses;
frequently the cells are increased in size with increased amounts of cytoplasm, pseudopod-like cytoplasmic
projections, peripheral cytoplasmic basophilia, enlarged irregularly shaped nuclei, and chromatin immaturity;
occasionally the cells have a plasmacytoid appearance.
Left shift increased numbers of bands and sometimes less mature neutrophils; frequently associated with
neutrophilia.
Leukemoid reaction leukocytosis with a left shift sometimes simulating leukemia (usually with a WBC of
>50,000/L).

BLOOD SMEAR LABORATORY


Case 1:
A 39-year-old woman presented to her physician with fatigue.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelets

WBC Differential:
9.6
4.07
8.4
29.3
72.0
20.6
28.7
19.8
540

Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils

65%
28%
5%
1%
1%

Questions:
1. From the CBC results, what do you expect to see on the blood smear? Focus on the RBC indices and
RBC morphology.
2. Examine the platelets, WBCs, and RBCs on the smear. Does your smear review correlate with the CBC
results? Describe the RBC morphology.
3. What is your differential diagnosis at this point?
4. Other laboratory data include:
Ferritin
5
Iron
28
TIBC
480
% saturation
6%
Reticulocyte count 1.0%
How do you interpret these results?
5. What questions would you ask the patient and what tests would you perform to ascertain the cause f the
hematologic disorder? What other tests are necessary for a diagnosis?
6. What is your diagnosis now?

Case 2:
A 22-year-old African American man with a history of anemia was seen in the emergency department with
complaints of severe leg pain.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW

WBC differential:
10.9
2.77
7.6
22.5
81.2
27.4
33.8
26.7

segmented neutrophils
bands
lymphocytes
eosinophils
nucleated RBCs

68%
2%
24%
6%
1/100 WBCs

Questions:
1. From these results, what do you expect to see on the blood smear?
2. Examine the smear looking at platelets, WBCs, and RBCs. Describe the red blood cell findings. Do you
see red blood cell inclusions?
3. What is your differential diagnosis at this point?
4. Physical exam revealed no palpable spleen and the patient was jaundiced. Laboratory studies revealed a
reticulocyte count of 8.4%, a total bilirubin of 3.2 mg/dL (normal: 0.3-1.2), and unconjugated bilirubin
of 2.4 mg/dL (normal: < 1.1).
Calculate the absolute reticulocyte count. Does this patient have a hemolytic anemia? What other tests
do you need for a definitive diagnosis?
5. The patient recovered after 48 hours and returned to work. Two years later, his Hct was noted to be
gradually falling to a level of 23% with a decrease in his reticulocyte count to 4%. His MCV was 119
fL. A peripheral blood smear revealed similar findings as seen above, but also the presence of oval
macrocytes and hypersegmented neutrophils. What is happening? The patient was treated appropriately
and his Hct returned to its previous level.
6. Six months later, the patient was readmitted 5 days after the onset of fever, cough, muscle aches, and
malaise during a flu-like illness. His Hct was 18% with a reticulocyte count of 0.5%. How do you
explain these results?

Case 3:
A 24-year-old healthy man was seen by a physician assistant for a routine physical examination and lab tests
prior to starting a new job.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelets

WBC differential:
8.7
3.8
12.9
36.8
96.8
33.9
35.1
12.0
339

Neutrophils
Lymphocytes
Monocytes
Eosinophils

Questions:
1. From these results, what do you expect to see on the blood smear?
2. Examine the smear. What do you see? Focus on the RBC morphology.
3. What is your differential diagnosis at this point?
4. What other tests, clinical information, etc., may be helpful?

53%
40%
4%
3%

Case 4:
A 76-year-old Italian man was admitted to the hospital for hernia repair. His history and physical examination
were unremarkable.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW

WBC differential:
4.89
5.91
11.7
36.7
62.1
19.8
31.9
11.5

Segmented neutrophils
Bands
Lymphocytes
Monocytes

60%
8%
22%
10%

Questions:
1. From these results, what do you expect to see on the blood smear?
2. Examine the smear looking at the platelets, WBCs, and red blood cells. What do you see? Focus on the
RBC morphology.
3. What is your differential diagnosis at this point?
4. Other laboratory data: reticulocyte count 1.3%; Fe, TIBC, % saturation, and ferritin are all normal.
Calculate the absolute reticulocyte count. Does this patient have a hemolytic anemia? What other tests
and clinical information would be helpful in establishing a diagnosis?
5. What is your diagnosis?

Case 5:
A 60-year-old white carpenter presented with a complaint of progressive weakness of 6 months duration. The
year before he had a normal physical examination.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCHC
RDW

5.6
2.57
9.9
30.9
120
32.0
18.5

Reticulocyte count

0.6%

WBC differential and platelet count are within normal limits.


Questions:
1. After examining the laboratory data, what do you expect to see on the smear?
2. Examine the smear? What do you see? Focus on the RBC and WBC morphology.
3. Calculate the absolute reticulocyte count. How do you interpret these results?
4. What is your differential diagnosis?
5. Predict the appearance of the bone marrow.
6. Additional history was unremarkable for diet, alcoholism, acute or chronic bleed, hypothyroidism, liver
disease, or malignancy. What other laboratory tests would aid in the diagnosis?
7. In this case, a serum vitamin B12 level was 47.3 (reference range 205 2,000 pg/mL) and a folate level
was 9.7 (reference range 1.6 2.0 ng/mL). What is your diagnosis now? Can you distinguish between a
vitamin B12 and folic acid deficiency based on examination of the peripheral blood smear and bone
marrow aspirate/ biopsy?
8. What are the most common causes of vitamin B12 and folic acid deficiencies?

Case 6:
A 28-year-old female college student presented to her physician with fever and sore throat. Physical
examination revealed cervical lymphadenopathy.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
Platelets

WBC differential:
16.8
4.76
14.0
43.0
90.3
31.3
34.7
250

Neutrophils
Lymphocytes
Monocytes
Eosinophils

28%
63%
8%
1%

Questions:
1. From the CBC results, what do you expect to see on the blood smear?
2. Examine the smear looking at platelets, WBCs, and RBCs. Do you see anything ususual about the white
blood cells?
3. What is your differential diagnosis at this point?
4. The physical examination revealed fever, pharyngitis, and cervical adenopathy. What other laboratory
data would you want at this time to confirm the diagnosis?
5. What is the most likely diagnosis?

Case 7:
A 42-year-old man came to the emergency department with recent onset of diffuse abdominal pain, fever, and
loss of appetite.
CBC results:
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
Platelets

WBC differential:
36.2
4.52
13.1
37.3
82.3
28.9
35.1
246

Segmented neutrophils
Bands
Lymphocytes
Monocytes

49%
37%
13%
1%

Questions:
1.

From the CBC results, what do you expect to see on the blood smear? Focus on the WBC
differential and morphology.

2.

Examine the smear looking at the platelets, WBCs, and RBCs. Examine the WBCs carefully.
What do you see?

3.

What is your differential diagnosis at this point? If the WBC was 60,000/L and numerous
immature granulocytes were present (promyelocytes, myelocytes, metamyelocytes), what diagnosis
would you suspect?

4.

What other tests, clinical information, etc., may be helpful?

UROGENITAL REPRODUCTIVE LABORATORY


Case #lB (92SP4960)
This 67-year-old male presented with a 4.5 x 2.5 x 2 cm grayish white friable, ragged mass with heaped up
margins at the tip of an uncircumcised penis. The mass had been slowly enlarging for several months. A total
penectomy was performed. In the laboratory this measured 6 x 2.5 x 2 cm. A representative section is available
for your review.
Questions:
Discuss the microscopic findings and diagnosis.
Discuss the risk factors and clinical features of the case.
Case #2A (93SP722)
This 46-year-old male presented with increasing difficulty in maintaining a urinary stream. A transurethral
resection of the prostate was performed. Curettings aggregating to 46 grams were received in the laboratory
(normal intact prostate gland weighs approximately 20 grams). A representative slide is available for your
review.
Case #2B (93SP1771)
This 68-year-old male presented with lumbosacral pain. Following a diagnostic needle biopsy of the prostate, a
radical prostatectomy was performed. This weighed 35 grams and on cut section showed peripheral small
yellowish nodules. A representative section of the prostatectomy specimen is available for your review.
Questions: Cases #2A and 2B
Discuss the microscopic findings and diagnosis.
What is the etiology and pathogenesis of these diseases?
Discuss the clinical features of each case.
Case #3C (92SP7945)
This 25-year-old male presented with a painless right testicular mass. Right radical orchiectomy was performed.
The testis contained a 2.4 x 1.5 x 1.2 cm firm, gray-white, lobulated tumor. There was no gross evidence of
hemorrhage or necrosis. A representative section is available for your review.
Case #3E (95SP2711)
This 31-year-old male presented with a palpable right testicular mass. Right radical orchiectomy was
performed. The enlarged testis contained a 3.5 cm, in greatest dimension, pale tan mass with areas of
hemorrhage and necrosis. A representative section is available for your review.
Questions: Cases #3C, and 3E
Discuss the microscopic findings and diagnosis.
How are tumors of the testes classified?
What are risk factors for testicular tumors?
What is the frequency of the different germ cell tumors?
With germ cell tumors, what serum markers are measured? How are they used?
How do seminomas and non-seminomatous germ cell tumors differ?

Case #4B (93SP1716)


This 72-year-old male presented with painless hematuria. A cystoscopy revealed multiple lesions that were
resected transurethrally. Pink-tan tissue aggregating to 4 x 4 x 1 cm was received in the laboratory. A
representative section is available for your review.
Case #4C (99SP734)
This 54-year-old white male saw his physician after developing gross hematuria. He also noted aching in
his lumbar area. A cystoscopy was performed revealing a bladder diverticulum containing a papillary
lesion. An abdominal CT scan revealed enlargement of the left iliac lymph nodes. The urinary bladder
diverticulum was resected and a representative section is available for your review.
Questions: Cases #4B and 4C
Discuss the microscopic findings and diagnosis.
Discuss risk factors and clinical features for each case.
How are tumors of the urinary bladder classified?
Case #5A (93SP6412)
A 72-year-old female presented with left flank pain, weight loss, and malaise. A left radical nephrectomy
was performed. Present within the superior pole of the kidney was a 5 x 4 x 2 cm orange wellcircumscribed mass with areas of hemorrhage. There was no tumor in the renal vein or renal pelvis. A
representative section is available for your review.
Questions: Case #5A
Discuss the microscopic findings and diagnosis.
Discuss risk factors and clinical features associated with this tumor.
Case SP1995-8537
A 53-year-old female had lumpy breasts and no discrete lesions. A 3 x 2 x 1 cm right breast biopsy revealed
predominantly white tissue, with scant fat and discrete bluish cysts. Hint: Look for normal breast tissue for
comparison to the abnormal tissue.
Case SP1998-5080
A 16-year-old female noted a 2 cm upper outer quadrant left breast mass present for one year. The nodule was
freely movable without fixation. There were no overlying skin changes or axillary adenopathy. At surgery the
nodule was circumscribed, multi-lobulated, and was entirely removed. The removed specimen measured 3.0 x
2.0 x 2.1 cm. Hint: Look at the stromal and glandular tissue.
Case SP1998-6041
A 78-year-old female on routine mammogram was found to have abnormal calcifications in the upper outer
portion of the left breast. There was no palpable mass or nipple discharge. Preoperatively a needle was placed in
the area of concern, and a 3.2 x 3 x 0.6 cm biopsy was removed. An ill-defined 2 cm nodule was present. Hint:
Look at the ducts and intervening stroma.

Case 99SP4182
This 22-year-old female had a routine Pap smear that was abnormal. A cervical cone biopsy was obtained. A
section is available for review.
Case 99SP2489
This 47-year-old female presented with vaginal bleeding. The specimen received in the laboratory was a
cervical cone biopsy that measured 4.3 x 4.0 x. 2.4 cm. The entire specimen was submitted for microscopic
examination. A representative section is available for your review.
Case 99SP2164
This 28-year-old female saw her physician for pelvic pain and dysmenorrhea. She had a large palpable right
adnexal mass. At laparotomy an 8 x 4 x 4 cm ovary was removed and sent to the laboratory. This cystic mass
was incised revealing a thin-walled cyst filled with thick brown opaque pudding-like material. Representative
tissue is available for review on one slide.
Case #2C
This 39-year-old female presented with excessive menstrual bleeding. Received in the laboratory was a
markedly distorted uterus containing multiple intramural, subserosal and submucosal whitish, wellcircumscribed discrete nodules ranging from 0.5 to 5 cm in greatest dimension. A representative section of a
nodule is available for evaluation.
Case 92SP9064
This 76-year-old female presented with postmenopausal bleeding. Received in the laboratory was a uterus with
attached bilateral fallopian tubes and ovaries. The 48.6 gram uterus measured 8.5 x 5 x 2 cm. The endometrium
measured 1 cm thick. A section of the endometrium and myometrium is available for diagnosis.
Case 93SP1072
This 26-year-old female underwent dilatation and curettage following abnormal bleeding in the eighth week of
pregnancy. Received in formalin were multiple whitish, sac-like tissue fragments with the appearance of
bunches of grapes. The total specimen weight was 90.4 grams. Sections show a representative sample.
Case 93SP5643
This 13-year-old female underwent exploratory laparotomy for a palpable pelvic mass. A large cystic mass
measuring 11.5 x 8 x 7 cm was received for examination. The cyst contained yellow, greasy, thick material with
matted hair. Parts of the cyst wall were thickened and other parts were calcified. Within a thickened area of the
wall a tooth was found. Representative tissue from the non-calcified area is submitted for review.
Questions:
Discuss the microscopic findings and the diagnosis.
Outline the classification of ovarian germ cell tumors
What features separate benign from malignant?

GI PATHOLOGY LABORATORY
SB-78-S-6670
A 32-year-old male is admitted with complaints of weakness, loose motions, and weight loss. A diagnosis of
malabsorption syndrome is made. Section of small bowel biopsy.
SB-82-3127
A 46-year-old female is admitted to the hospital because of sudden onset of a cramping abdominal epigastric
pain. At surgery 2 feet of gangrenous ileum is found. Section from bowel.
SBA-5-82
A 56-year-old male admitted to the hospital because of unsteady gait. Previous significant history of alcoholism
and pancreatic carcinoma treated at Barnes Hospital by cholecystojejunostomy. During this admission the
patient remains febrile, and Streptococcus viridans is isolated from 5 to 6 blood culture bottles. CT scan of liver
compatible with hepatoma involving left lobe of liver. Patient died after 2 weeks of hospitalization. Autopsy
performed. Sections of liver and pancreas.
SBL-3200-82
A 63-year-old male admitted to the hospital with a 3 cm sessile tumor of the rectum. Three years before a
polyp of rectum noted on sigmoidoscopy and Barium enema. Segmental resection of rectum performed.
Sections of tumor and lymph node.
SB-1571-78
A 70-year-old female entered the hospital with fatigue and hemoglobin of 10 gm/dL. Barium enema
demonstrated a narrow segment of transverse colon measuring 12 cnL. Small bowel examination normal.
Gross exam: a segment of colon measuring 15.0 x 5.0 cm removed. The wall measures 1.0 cm thickness and is
rigid. The lumen of the bowel is narrowed to approximately .05 cm in diameter. The mucosa demonstrated
confluent ulcers with a linear distribution. The mucosa demonstrates a definite cobble-stone appearance.
Section from colon.
Unknown Case
Slides will be provided during class.

HINTS FOR GI LABORATORY


SB-78-86670
From the history a broad diagnosis of malabsorption syndrome can be made. What are the different forms of
malabsorption syndrome?
Find a good picture of normal small bowel mucosa and compare the villi in this case with the normal one.
1. What is the size of the villi?
2. What are the empty round spaces?
3. What type of cells have infiltrated the villi?
One of the slides in the case has PAS stain.
1. What is the basic significance of PAS stain?
2. Do normal macrophages stain positive with PAS?
Your diagnosis: ________________________________________________________________________
SB-82-3127
The history and surgical finding provide a good clue for the diagnosis. Under the microscope, look for normal
mucosa and a large hemorrhagic area. Look for:
1.
2.
3.
4.

The extension of the ischemic damage


Mucosae ulceration
Inflammation
Engorged blood vessels

Your diagnosis: ________________________________________________________________________


SBA-5-82
Please do not let the complex history confuse you. Look at the slides first.
Liver: under low power you should be able to identify the abnormal tissue from the normal. Examine the whole
slide for areas of inflammation and necrosis and possibly a neoplasm.
Pancreas: look for normal pancreas (only a few glands are present), but there is chronic inflammation, fibrosis,
and nerve bundles.
Now, correlate the findings with the case history.
The diagnosis is: _________________________________________________________________________

SBL-3200-82
From the case history it can be concluded that the slides will be of:
Tumor:
1. The general arrangement is: _______________________________________________________
2. Look for the malignant criteria in the tumor.
Lymph nodes:
Compare the 2 of them.
The diagnosis is: ______________________________________________________________________
The Dukes staging is: __________________________________________________________________

SB-1571-78
The case history suggests inflammatory bowel disease.
The characteristics of the case under the microscope are: _________________________________________

The diagnosis is: __________________________________________________________________________