Familiar with driving, hand to “bird”

[2022 Blood and Body Fluids Case Show Final Manuscript]

Author | Baiyun 1 Li Nianying 2

Unit | Department of Laboratory Medicine, Xi’an Third Hospital: 1. Department of Laboratory Medicine; 2. Department of Neurology

Foreword

In this case, the patient was previously diagnosed with gastric cancer, underwent subtotal gastrectomy and cholecystectomy, and planned chemotherapy for 6 times after surgery, but was terminated due to severe nausea and vomiting. In April 2022, the patient visited the local hospital twice successively due to symptoms such as headache, headache and nausea and vomiting after working in the field and catching cold. The patient was hospitalized twice in the local area. The local hospital only performed routine and biochemical tests of cerebrospinal fluid, but did not perform cytological examination of cerebrospinal fluid. In terms of treatment, the local hospital only treated symptoms, and did not trace the root cause of the disease and treat the cause.

In May 2022, the patient came to our hospital for further hospitalization. The neurologist of our hospital performed a lumbar puncture for the patient after admission, and performed routine, biochemical, cytological and other related examinations on the cerebrospinal fluid. Dealing with it at one time and making a clear judgment in a very short period of time play an important role in clinical diagnosis and treatment.

Case History

A 68-year-old male patient was admitted to the hospital because of the chief complaint of “headache accompanied by nausea and vomiting for more than 20 days”. History of present illness: The family member complained that the patient suffered from headache and headache more than 20 days ago after working in the field and catching cold. The headache was persistent, mainly in the frontal and occipital region, accompanied by nausea, retching, vomiting, feeling weak and unable to go to the field. , Poor mental appetite, no blurred vision, no temperature measurement, no chills, cough, sputum, runny nose, no nonsense, swallowing and coughing, no limb movement, nonsense, abnormal mental behavior and other symptoms.

The next day, he was hospitalized in the Cardiology Department of a local tertiary hospital. The blood pressure was measured at 184/88mmHg, and he was given treatment such as controlling blood pressure and improving heart function. The symptoms did not significantly relieve, and then he was transferred to the Department of Neurology. The lumbar puncture examination showed that the intracranial pressure was 240mmH2O, and the white blood cells in the cerebrospinal fluid 8×106/L, glucose 1.71mmol/L, chloride and protein levels were normal, and after symptomatic treatment such as reducing intracranial pressure, improving circulation, and controlling blood pressure, the symptoms were slightly relieved and he was discharged from the hospital.

On May 6, 2022, the patient’s headache symptoms became worse than before, accompanied by nausea and retching, so he went to the hospital again for treatment. A lumbar puncture reexamination showed that the intracranial pressure was 300mmH2O, the white blood cells in the cerebrospinal fluid were 26×106/L, and the glucose was 0.96mmol/L. Chloride and protein levels were normal, and antiviral and intracranial pressure lowering treatments were given (the details are unknown), but the symptoms were not significantly relieved.

On May 10, 2022, the patient went to the emergency department of Xi’an for treatment. A reexamination of the lumbar puncture revealed that the intracranial pressure was >330H2O, the white blood cells in the cerebrospinal fluid were 10×106/L, the glucose was 2.0 mmol/L, and the chloride and protein levels were normal. Ganciclovir was given. 0.25g of anti-virus, mannitol to lower intracranial pressure, fluid support and other treatments.

On May 12, 2022, the patient came to our hospital for further inpatient diagnosis and treatment, and was hospitalized with “central nervous system infection” in the emergency department.

Pre-admission check

Past history: Hypertension for 3 years, the highest 180/90mmHg, usually taking amlodipine and benazepril tablets 12.5mgbid. He was diagnosed with depression in a local hospital 6 years ago. He is currently taking escitalopram oxalate 10mgqd and his condition is stable. He has a history of benign prostatic hyperplasia for 5 years and is currently taking tamsulosin 0.2mgqn. Gastric cancer was diagnosed in a local hospital two years ago, subtotal gastrectomy and cholecystectomy were performed, and chemotherapy was performed twice after surgery (the original plan was 6 times, but it was terminated due to severe adverse reactions of nausea and vomiting).

1. Physical examination: body temperature 36°C, pulse 61 beats/min, respiration 18 beats/min, blood pressure 95/67mmHg. The breath sounds of both lungs were clear, no wet or dry rales were heard, the heart rate was 61 beats/min, the heart rate was regular, no obvious murmurs were heard, the abdomen was soft, sunken, no tenderness and rebound tenderness, the liver, spleen and ribs were not palpable, There was no edema in the lower extremities.

2. Nervous system examination: clear consciousness, sharp language, lack of cooperation in physical examination. Orientation, memory, calculation, and comprehension cannot cooperate.

3. Outpatient examination and inspection (5.12 a large tertiary hospital in Xi’an)

Blood routine: WBC6×109/L↑, N%77.9%↑; PCT0.147ng/mL; urine red blood cell qualitative 3+, urinary white blood cell qualitative 1+, urine red blood cell quantitative 75.6/uL, urine white blood cell quantitative 96.4/uL; D2 Polymer 1.04ng/L; Potassium 2.74mmol/L, Sodium 130.4mmol/L, Chlorine 93.7mmol/L.

4. Ultrasound examination (5.12 a large tertiary hospital in Xi’an)

Bradycardia, aortic sclerosis, aortic valve calcification, decreased left ventricular diastolic function, aortic regurgitation (a small amount); liver, gallbladder, pancreas, spleen, and kidney ultrasound showed no abnormalities.

5. Chest CT (May 12, a large tertiary hospital in Xi’an)

Several small nodules scattered in both lungs are basically the same as before. Follow-up observation is recommended. The bullae in the middle lobe of the right lung and lower lobe of the left lung are the same as before.

6. Head MRI+MRA+MRV (5.10 a local tertiary hospital)

Multiple lumen stems, protein demyelination; brainstem demyelination changes, right dominant venous sinus. Cranial MR enhancement: The tentorium and bilateral parietal and occipital meninges are slightly thickened and enhanced.

7. After hospitalization, complete relevant inspections in the laboratory department

Cytological examination of cerebrospinal fluid: On the afternoon of May 13, 2022, a lumbar puncture was performed clinically on the patient, and the cerebrospinal fluid was submitted for routine, biochemical, bacterial, fungal, acid-fast bacilli, cryptococcus and other examinations, as well as cytological examination of cerebrospinal fluid. After the specimens were sent to the laboratory, the staff immediately tested them on the machine, stained the slides, and observed them under a microscope. Under the microscope, a large number of scattered or piled abnormal cells can be seen. The cells are of different sizes, the cytoplasm is strongly basophilic, the nucleus is large, and the nucleolus is obvious. Combined with the patient’s history of gastric cancer, metastatic tumors of the central nervous system are considered.

Consider meningeal metastases.

Cerebrospinal fluid cytology report

Discharge diagnosis

1. Cancerous meningitis

2. Increased intracranial pressure (very high risk)

3. After radical gastrectomy

4. Electrolyte disturbance

5. Hypoproteinemia

6. Urinary Tract Infection

7. Prostatic hyperplasia

8. Grade 3 hypertension (very high risk)

9. Depressed state

Clinical Case Analysis

The patient was an elderly male with an acute course of disease. After catching a cold, he developed headache and neck pain, accompanied by nausea and vomiting. Intracranial infection and increased intracranial pressure were first considered clinically. The patient completed two lumbar puncture examinations in the local hospital. The CSF pressure was 240~300mmH2O, both of which indicated intracranial hypertension. The cell counts were 8×106/L and 26×106/L respectively. Compounds were normal, no cerebrospinal fluid cytology examination was performed, and only antiviral and intracranial pressure lowering treatments were given. The patient’s symptoms did not improve, so he came to Xi’an for treatment.

When I received the patient on the night of duty, I had the initial impression that the overall condition of the patient was poor and malnourished. During the physical examination, he was in poor spirits, had headaches, irritability, and poor cooperation. . When I saw the cerebrospinal fluid test performed by the local hospital, I found that the characteristics of the two cerebrospinal fluid tests were not in line with the conventional viral meningitis, tuberculous meningitis, bacterial meningitis and fungal meningitis. At that time, I doubted whether it would be possible. Is it some other specific type of infection or tumor?

So I decided to re-examine the lumbar puncture the next day, and improve the routine and biochemical cytology of the cerebrospinal fluid. The results of the cerebrospinal fluid still showed that the number of cells was normal, the glucose was significantly lower, but the protein and chloride were normal.

The superior physician conducted a detailed analysis after examining the patient: Middle-aged and elderly patients with headache, cranial nerve palsy, and meningeal irritation, especially those with a history of tumors, should be alert to meningeal cancer. The patient had a subacute course of disease, with progressive aggravation of neurological symptoms, mainly manifested as headache, nausea, and vomiting, which supported the clinical diagnosis of meningeal involvement.

The patient had a history of gastric cancer surgery two years ago. The pressure of the cerebrospinal fluid was significantly increased, the white blood cell count and protein were normal, but the glucose was low. The characteristics of the cerebrospinal fluid tended to be meningeal carcinomatosis. After being admitted to the hospital, the patient was given mannitol and glycerin fructose dehydration to lower intracranial pressure, and oxycodone paracetamol for pain relief. After symptomatic treatment, the symptoms were still not relieved. The patient had high intracranial pressure, nausea, and vomiting, and there was a risk of brain herniation at any time. The condition was critical and unbearable. wait.

However, the diagnosis of the disease requires the support of the results of cerebrospinal fluid cytology, and clinical examination sometimes requires multiple inspections. Therefore, we urgently contacted the laboratory to inquire about cerebrospinal fluid cytology. : “Find a large number of abnormal cells, consider tumor cells”. Since then, within one day after the patient was admitted to the hospital, the diagnosis was confirmed, which also provided a direction for subsequent diagnosis and treatment.

Clinically speaking, cerebrospinal fluid cytology is the “gold standard” for the diagnosis of meningeal cancer, and it is of great significance for the early diagnosis of meningeal cancer, which cannot be replaced by imaging. For those with a history of malignant tumors, unexplained hydrocephalus or brain symptoms, the diagnosis is not clear and anti-infective treatment is ineffective, the possibility of meningeal cancer should be considered.

In addition, for middle-aged and elderly patients who have headache symptoms without obvious incentives and general analgesics cannot relieve pain, and whose physical examination is positive for meningeal irritation signs, the possibility of meningeal cancer should be highly suspected, and cerebrospinal fluid cytology should be actively performed. In close contact with medical testing, to inform its preliminary clinical judgment, it is necessary for the staff of the laboratory to find tumor cells with “piercing eyes” to confirm the diagnosis as soon as possible.

The patient is an elderly male. In April 2022, the patient visited the local hospital twice successively due to symptoms such as headache, headache and nausea and vomiting after working in the field and catching cold. In order to seek further diagnosis and treatment, the patient went to Xi’an for examination, and after completing relevant examinations in Xijing Hospital, he was hospitalized in the Third Hospital of Xi’an.

On the day of admission, the patient underwent a lumbar puncture, and the cerebrospinal fluid samples were sent to the laboratory for relevant examinations, including cerebrospinal fluid routine, biochemical, bacterial, fungal, acid-fast bacilli, cryptococcal examinations, etc.; the routine count was normal, and the biochemical index chloride , low sugar, bacteria, fungi, acid-fast bacilli, cryptococcus were not detected.

However, the staff of the clinical inspection team of the laboratory soon detected a large number of tumor cells in the patient’s colorless and clear cerebrospinal fluid specimen with a white blood cell count within the normal reference range, and immediately reported the results to the doctor in charge.

Test case analysis

The cerebrospinal fluid sample of this patient is colorless and clear, and the WBC count is 5×106/L. From the results of conventional counting, we can consider this to be a normal cerebrospinal fluid. However, the scatter diagram on the right side of the instrument data interface appears There are some abnormal scatter points (areas marked in red circles), and normal specimens should not have scatter points at these positions.

Check the special parameters of the laboratory, the data shows that the total number of nucleated cells in this specimen is 13×106/L, the white blood cell count is 5×106/L, of which HF-BF# is 8×106/L, and HF-BF% is 160/100WBC .

These scattered points with high fluorescence signal intensity and their ratio suggest that there may be a large number of abnormal cells in this specimen.

After the patient was admitted to the hospital, the doctor sent the cerebrospinal fluid cytology specimen for examination immediately. Assuming that the clinical examination was not submitted, the experienced staff of the laboratory department would also take the initiative to do cytology after seeing such a scatter plot and related data. Further communicate with the clinic and provide strong support for clinical diagnosis and treatment in a timely manner.

As we all know, the work of the clinical inspection team of the laboratory department is complicated and trivial. How can the staff quickly judge which specimens may have problems among a pile of cytology specimens, and need to deal with them as soon as possible and feed back the results to the clinic? This requires a solid form To learn the basics, we also need to master the detection principle, related parameters, graphics, alarm information, etc. of automatic instruments, and make full use of the relevant information provided by the instruments to make our work efficient, fast, and get twice the result with half the effort.

knowledge development

01

brain tumor

Brain tumors refer to new organisms growing in the cranial cavity, also known as intracranial tumors and brain cancers, which can originate from the brain, meninges, nerves, blood vessels, and brain appendages, or form by metastasizing from other tissues or organs of the body into the brain , Most of them can produce intracranial hypertension, dizziness, headache, nausea, vomiting and focal symptoms. It needs to be differentiated from infectious diseases of the central nervous system, subarachnoid hemorrhage, and low intracranial pressure headaches.

The most common source of brain metastatic tumors is bronchial lung cancer, about 40% of which have brain metastases, followed by about 25% of breast cancer. Brain metastases can occur in other tumors such as gastric cancer, colon cancer, kidney cancer and melanoma, especially melanoma brain metastases can reach 15%.

02

Blood cell analyzer body fluid mode

The XN series hematology analyzer is equipped with the BF mode for detecting body fluids. This channel uses special fluorescent dyes to enter cells and stain nucleic acids and small organs of cells. In addition to white blood cell count and cell classification, abnormal cells (such as mesothelial cells and epithelial-derived tumor cells) can also be detected, and the scatter points (HF-BF) in the area of ​​high fluorescent signal in the scatter plot suggest that there may be abnormalities in the specimen cells, and the density of scattered points is proportional to the number of abnormal cells.

Summary

In this case, the patient went to the local hospital for diagnosis and treatment due to headache accompanied by nausea and vomiting. Combined with the patient’s history of gastric cancer (subtotal gastrectomy was performed two years ago, chemotherapy was planned for 6 times after the operation, and it was discontinued due to severe adverse reactions such as nausea and vomiting), except Infection, etc. should also consider the possibility of tumor meningeal metastasis.

The patient was hospitalized in the local hospital twice and only underwent routine cerebrospinal fluid, biochemical tests and other tests. It was only symptomatic treatment. In fact, the cause of the patient’s headache, nausea and vomiting was not clarified.

If the local hospital can carry out cytological examination of cerebrospinal fluid, it will definitely be able to determine the cause of the disease. Firstly, it will treat the symptoms and causes, and secondly, it can avoid the burden of patients traveling to other places for medical treatment. The travel and various expenses are stressful for patients and burden.

In the absence of obvious abnormalities in the imaging examination, and the small amount of cerebrospinal fluid samples made it difficult to make a pathological diagnosis methodologically, the cause of the patient could be determined quickly in our hospital. The full trust of the laboratory department is inseparable. On the other hand, it also benefits from the continuous pursuit of professional theoretical knowledge, practical skills and work efficiency by the laboratory staff.

With the development and progress of modern medical technology, the level of diagnosis and treatment of central nervous system diseases has been greatly improved, but cytological diagnosis of cerebrospinal fluid is still an irreplaceable technology.

Cytological examination of cerebrospinal fluid is of great value in the diagnosis, differential diagnosis, curative effect observation and prognosis evaluation of central nervous system infectious diseases, meningeal cancer, central nervous system leukemia, lymphoma, cerebrovascular disease and other diseases.

As far as this technology is concerned, the operation is not complicated. For samples with a small amount of samples and a small number of cells, cytoslide centrifugation can increase the positive rate, and the inspection fee is relatively low. All hospitals with conditions should carry out , to benefit more patients.

Expert Reviews

Chang Mingze, Director of the Second Ward of the Department of Neurology

Cerebrospinal fluid cytology is the gold standard for the diagnosis of meningeal cancer, which is of great significance for the early diagnosis of meningeal cancer. When only the brain parenchyma metastases occur but the meninges and subarachnoid space are not involved, the routine, biochemical, and cytological changes in the cerebrospinal fluid may not be obvious; Abnormal cells can help clinical diagnosis quickly. In this case, the patient was hospitalized twice in the local hospital for diagnosis and treatment, but the symptoms did not improve significantly; the patient came to our hospital for further treatment. After examination, the Laboratory Department clearly judged that the tumor had meningeal metastasis within a very short period of time after receiving the specimen, which played an extremely important role in our clinical diagnosis and treatment. Cytological examination of cerebrospinal fluid is also an important basis for the diagnosis and differential diagnosis of other central nervous system diseases, and the laboratory department provides strong support for clinical practice in this regard.

references

[1] Xu Shaoqiang, “Cerebrospinal Fluid Cytology Atlas and Clinical Diagnosis Ideas”, People’s Health Publishing House, March 2021

[2] Li Xiuchu, “Practical Color Atlas of Cerebrospinal Fluid Cytology”, People’s Military Medical Press, June 1989

[3] Guidelines for Diagnosis and Treatment of Central Nervous System Metastatic Tumors

Note: This article is an original contribution and does not represent the views of new media in laboratory medicine. Please indicate the source and the name and unit of the original author when reprinting.

Thank you: Thank you Sysmex Medical Electronics (Shanghai) Co., Ltd. for your strong support to [2022 National Inspection and Clinical Cases (Blood and Body Fluids) Exhibition]!

Editor: Xu Shaoqing Reviewer: Chen Xueli