A mysterious malady: the Malachowski-Wright-Giemsa stain to the rescue.

A patient entered hospital with a puzzling absolute monocytosis. Admitting blood smears had been stained with Diff-Quik, a Romanowsky stain. When additional smears were stained using a standard Malachowski-Wright-Giemsa method, the reason for the monocytosis became abundantly clear.

The CBC at the turn of the millennium: an overview.

This review offers a birds-eye view of the state of automated hematology at the turn of the millennium. Despite its shortcomings (mainly flaggings and labor-intensive demands for confirmation), instrument-driven hematology provides much accurate and precise data to clinicians. Advances in technology over the next few decades will undoubtedly improve on the categorization of currently ambiguous mononuclear cells and even introduce channels for the detection and subclassification of poikilocytes. Until then, familiarity with the morphology of blood cell variants will be mandatory for technologists attending to the demands of flagging.

State action antitrust immunity for public hospitals: it depends on what you mean by "foreseeable".

The Supreme Court's refusal to hear an appeal from the Fifth Circuit's ruling on the application of state action antitrust immunity doctrine leaves a split in the circuits as to the proper test to apply to determine antitrust immunity for public hospitals. The circuits have either adopted a "foreseeable conduct from state policy" approach or a "policy from foreseeable conduct" approach. This Article analyzes the approaches and demonstrates that the "foreseeable conduct from state policy" approach is the better of the two methods.

Cytoplasmic inclusions in leukocytes. An unusual manifestation of cryoglobulinemia.

Cryoglobulins are circulating immunoglobulins characterized by reversible, cold-induced precipitation. A variety of laboratory abnormalities, including hypocomplementemia, elevated erythrocyte sedimentation rate, rheumatoid factor activity, pseudoleukocytosis, and pseudothrombocytosis, are associated with cryoglobulinemia. Extracellular, faintly basophilic, amorphous deposits of cryoglobulins occasionally have been described in blood smears. In the present study, smears prepared from blood collected at room temperature from 6 patients with cryoglobulinemia exhibited neutrophil and, occasionally, monocyte inclusions containing clear, light pink, or faintly basophilic amorphous material. The inclusions were absent in smears from blood collected and maintained at 37 degrees C. Ultrastructural examination revealed that the material within the leukocyte inclusions was consistent with phagocytosed immunoglobulins. The identification of characteristic cytoplasmic inclusions in leukocytes may be an important clue in the early recognition of cryoglobulinemia.

A multilobular variant of hairy cell leukemia with morphologic similarities to T-cell lymphoma.

Hairy cell leukemia is a distinct chronic lymphoproliferative disorder composed of morphologically unique B-lymphocytes. The diagnosis of hairy cell leukemia is usually based on the morphology of blood/bone marrow aspirate smears and bone marrow sections. We report three cases of hairy cell leukemia that had an unusual multilobated nuclear appearance seen on both smears and tissue sections. Many of the hairy cells exhibited marked nuclear lobulations and convolutions, giving rise to clover leaf-like nuclear configurations. The nuclear chromatin was finely reticular and characteristic of hairy cell leukemia. Bone marrow sections were hypercellular and the leukemic infiltrate was loosely distributed. A leukemic infiltrate was also seen in splenic sections in two cases in which splenectomy was carried out. Tartrate-resistant acid phosphatase cytochemistry was positive in all three cases. Flow cytometric analysis and paraffin section immunoperoxidase studies confirmed the B-cell lineage of the leukemic cells in all cases. The multilobulated nuclei described in these three cases are quite unusual in hairy cell leukemia; they could potentially lead to an erroneous diagnosis of T-cell lymphoma or leukemia. Features typical of hairy cell leukemia, such as the nuclear chromatin distribution and pattern of bone marrow infiltration, together with the clinical history, are helpful in establishing a correct diagnosis of these variant cases of hairy cell leukemia.

SQ 28,332, a new monobactam produced by a Flexibacter sp. Taxonomy, fermentation, isolation, structure determination and biological properties.

A new monobactam SQ 28,332 has been isolated from fermentations of a Flexibacter sp. and the structure 3 was deduced from its spectroscopic properties. SQ 28,332 exhibits weak antibacterial activity.

Heinz-body anemia: "bite cell" variant--a light and electron microscopic study.

Light and scanning electron microscopic studies of blood from five patients with drug-induced oxidant hemolysis are presented. None of the patients had a previous history of hemolytic disease and laboratory studies indicated no evidence of either glucose-6-phosphate dehydrogenase (G6PD) deficiency or unstable hemoglobinopathy. Although the red cell deformities in our patients overlapped to some extent with those reported in patients with microangiopathic hemolytic anemia (MAHA) and in patients with G6PD deficiency undergoing oxidant hemolysis, striking differences were also observed. Cell fragments, commonly found in patients with MAHA, and eccentrocytes, frequently found in patients with G6PD deficiency undergoing oxidant hemolysis, were seldom found in blood samples from the five patients in this study. Bite cells were extremely common in our patients. They are rare in patients with either of the above disorders. An awareness of the morphologic abnormalities detailed in this report may help characterize the nature of a hemolytic process so that appropriate therapy can be initiated.

Interpretation of ascitic fluid data.

Except in the case of chylous or hemorrhagic effusion, the gross appearance of ascitic fluid is not especially helpful in the investigation of ascites of unknown origin. The differential diagnosis of ascites rests on more objective data obtained from chemical and cytologic analyses. Both routine and special ascitic fluid tests are listed here, and test results are interpreted as they apply to four major disease states.

Isolation of an inhibitor of hepatic cholesterolgenesis from human milk.

Two preparations active in reducing hepatic cholesterolgenesis in vitro were demonstrated in human milk. These appear to affect the cholesterol synthetic pathway at different loci. One inhibits the synthesis before the formation of mevalonic acid and has been isolated and subsequently identified as uric acid. The other inhibitor has yet to be identified. The apparent paradox of the active component being uric acid, of which high levels are known to cause gout, is discussed.

Interpretation of blood chemistries, part 1.

Multichannel biochemical analyzers, which simultaneously measure numerous chemical constituents of blood and provide a printout of results in a matter of minutes, have become useful diagnostic tools in modern medical practice. This two-part article shows by actual examples how to make the most of such data in diagnosing disease and monitoring its course. Part 2 will be published next month.

Renal dysfunction. 2. Proteinuria.

Proteinuria greater than 150 mg/24 hr without antecedent strenuous exercise demands an explanation. As an aid in the search for that explanation, this article provides a simple, logical classification of the various causes of proteinuria. Part 1 of this two-part article, published last month (page 93), discussed urea and creatinine.

Renal dysfunction. 1. Urea and creatinine.

Serum urea is more frequently increased in nonrenal than in renal disease, a fact that blunts its diagnostic usefulness. The serum creatinine is probably the most useful of commonly available tests for both detecting and monitoring renal disease, but it is not without its shortcomings. Serum urea/creatinine ratios are generally supportive of clinical impressions but are subject to so many variables as to be too tenuous for diagnostic purposes, especially in acute renal failure. Measured creatinine clearances are still widely performed but are subject to so many variables (none the least of which is inaccurate urine collection) as to warrant abandonment. Estimated creatinine clearances are reasonably accurate, but indications for their use are relatively limited.

Cerebrospinal fluid data. 2. Interpretation in intracranial malignancy and multiple sclerosis.

In malignancies involving the CNS, notably leukemia, malignant cells may be readily demonstrated in the CSF, directly confirming the diagnosis. Advances in cell isolation techniques have significantly increased the diagnostic yield of CSF cytology. A variety of CSF protein studies and both WBC and differential counts are central to the diagnosis of multiple sclerosis. Protein studies include total protein levels, gamma globulin levels, and electrophoretic techniques designed to demonstrate the fine structure of gamma globulin, ie, its separation into two to ten (or more) oligoclonal bands. Although by no means specific for multiple sclerosis, such bands are strongly supportive of the diagnosis in the correct clinical setting.

Cerebrospinal fluid data. 1. Interpretation in intracranial hemorrhage and meningitis.

In substantiating a diagnosis of intracranial hemorrhage, the most important laboratory findings are RBCs, free hemoglobin, or hemoglobin breakdown products in the CSF. When the Gram stain is negative and results of bacterial, viral, and fungal cultures are pending. CSF WBC and differential counts and glucose and lactic acid levels may provide clues to the cause of meningitis. In addition, counterimmuno-electrophoresis and other immunologic techniques that facilitate the diagnosis of meningitis are now becoming more widely available.