AAaplastic anaemiaALacute leukaemiaALKanaplastic lymphoma kinaseALLacute lymphoblastic leukaemiaALPalkaline phosphataseALTalanine transaminaseAMLacute myeloid leukaemiaANAantinuclear antibodyAPLacute promyelocytic leukaemiaAPTTactivated partial thromboplastin timeASTaspartate transaminaseATLLadult T‐cell leukaemia/lymphomaBLBurkitt lymphomaccytoplasmicCDcluster of differentiationCHOPcyclophosphamide, doxorubicin, vincristine and prednisoloneCLLchronic lymphocytic leukaemiaCMLchronic myeloid leukaemiaCMMLchronic myelomonocytic leukaemiaCNScentral nervous systemCRPC‐reactive proteinCSFcerebrospinal fluidCTcomputed tomographyDICdisseminated intravascular coagulationDLBCLdiffuse large B‐cell lymphomaDNAdeoxyribonucleic acidEBVEpstein–Barr virusESRerythrocyte sedimentation rateETessential thrombocythaemiaFISHfluorescence in situ hybridisationFDGfluorodeoxyglucoseFLfollicular lymphomaGPgeneral practitionerH&Ehaematoxylin and eosin (stain)HCLhairy cell leukaemiaHLHodgkin lymphomaHLA‐DRhuman leukocyte antigen DRHTLV‐1human T‐cell lymphotropic virus type 1IgimmunoglobulinIgAimmunoglobulin AIgGimmunoglobulin GIgMimmunoglobulin Miuinternational unitLBLlymphoblastic lymphomaLDHlactate dehydrogenaseLGLlarge granular lymphocyteLPDlymphoproliferative disorderMCLmantle cell lymphomaMDSmyelodysplastic syndromeMDS/MPNmyelodysplastic/myeloproliferative neoplasmM:Emyeloid:erythroidMGGMay–Grünwald–Giemsa (stain)MPNmyeloproliferative neoplasmMPOmyeloperoxidaseMRImagnetic resonance imagingNLPHLnodular lymphocyte predominant Hodgkin lymphomaNRnormal rangeNRBCnucleated red blood cellsPETpositron emission tomographyPCRpolymerase chain reactionPRCApure red cell aplasiaPTprothrombin timeR‐CHOPrituximab, cyclophosphamide, doxorubicin, vincristine and prednisoloneRNAribonucleic acidRSReed–SternbergSLEsystemic lupus erythematosusT‐ALLT‐lymphoblastic leukaemiaTdTterminal deoxynucleotidyl transferaseT‐LBLT‐lymphoblastic lymphomaTTthrombin timeuunitWMWaldenström macroglobulinaemia
Normal ranges for commonly used tests (for adults)
FBC and differential count
| Males | Females | ||
| WBC (× 109/l) | 3.7–9.5 | 3.9–11.1 | |
| RBC (× 1012/l) | 4.32–5.66 | 3.88–4.99 | |
| Hb (g/l) | 133–167 | 118–148 | |
| MCV (fl) | 82–98 | ||
| MCH (pg) | 27.3–32.6 | ||
| MCHC (g/l) | 316–349 | ||
| Neutrophils (× 109/l) | 1.7–6.1 | 1.7–7.5 | |
| Lymphocytes (× 109/l) | 1.0–3.2 | ||
| Monocytes (× 109/l) | 0.2–0.6 | ||
| Eosinophils (× 109/l) | 0.03–0.46 | ||
| Basophils (× 109/l) | 0.2–0.29 | ||
| Platelets (× 109/l) | 143–332 | 169–358 | |
From Bain BJ (2017) A Beginner’s Guide to Blood Cells, 3rd Edn. Wiley Blackwell, Oxford.
Coagulation tests
| Prothrombin time | 9–13 s |
| Activated partial thromboplastin time | 27–38 s |
| Thrombin time | 11–15 s |
| Fibrinogen | 2–4.5 g/l |
| D dimer | <230 ng/ml |
Other tests
| Albumin | 35–50 g/l |
| Ferritin | 15–300 μg/l (males); 14–200 μg/l (females) |
| Bilirubin | 1–20 μmol/l |
| Alanine transaminase | 0–50 u/l |
| Aspartate transaminase | 0–40 u/l |
| Alkaline phosphatase | 30–130 u/l |
| C‐reactive protein | <5 mg/l |
| Erythrocyte sedimentation rate | <10 mm in 1 h (males); <20 mm in 1 h (females) |
1 Anaplastic large cell lymphoma with haemophagocytic syndrome
A 50‐year‐old man from another health board was transferred to a local hospital for a surgical biopsy of a mediastinal lymph node. He had presented 6 weeks previously with fever, sweats and weight loss. No infective or neoplastic aetiology had been identified. He had progressive pancytopenia and hyperferritinaemia and a diagnosis of idiopathic haemophagocytic syndrome had been considered. He had already been treated at the base hospital with corticosteroids and etoposide. CT imaging, however, had shown abnormal mediastinal lymph nodes, which would not have been accessible by percutaneous needle biopsy.
On arrival at the local cardiothoracic unit he was clearly unwell. The full blood count showed Hb 90 g/l, WBC 2.5 × 109/l, neutrophils 1.5 × 109/l and platelets 25 × 109/l. The coagulation screen showed PT 18 s, APTT 45 s, TT 18 s, fibrinogen 1.4 g/l and D dimer 5500 ng/ml (NR <230). Serum ferritin was >10 000 μg/l. The anaesthetic team phoned to ask for advice regarding management of the coagulopathy prior to surgery. The blood film showed rouleaux and was leucoerythroblastic with a few toxic granulated neutrophils but no neoplastic cell population was evident. We decided to cancel the surgery, review the imaging and perform a bone marrow aspirate and trephine biopsy. A CT scan showed definitely pathological mediastinal lymph nodes. The bone marrow aspirate showed a population of very large lymphoid cells with round or ovoid nuclei, indistinct nucleoli and partially condensed nuclear chromatin without cytoplasmic granules (top images). The cytoplasm of these cells showed prominent vacuolation, often concentrated in apparent pseudopodia (top images). In addition, there was a substantial population of macrophages showing haemophagocytosis, particularly of red cells and their precursors (all images above ×100 objective). The clinical, laboratory and morphological findings were in keeping with a haemophagocytic syndrome. Flow cytometry on the large cell population in the marrow aspirate showed these