PacificPathology TrainingCentre

Phil Wakem NZCSc, Dip MLSc, MMLSc (Otago,NZ), MNZIMLS, RNZMLS

Chief Executive OfficerPacific Pathology Training CentreWHO Collaborating Centre for External Quality Assessment in Health Laboratory ServicesWellingtonNew Zealand

The PPTC• Not-for-profit organisation. • Established in 1980 • 1990 – recognised as a WHO Collaborating Centre for External Quality Assessment.• PPTC is supported by –

- New Zealand Government, the Ministry of Foreign Affairs and Trade (MFAT)- World Health Organization (WHO)- United Nations Development Programme (UNDP)- New Zealand Institute of Medical Laboratory Sciences (NZIMLS)- New Zealand Red Cross (NZRC)- Norman Kirk Trust (NKT)- New Zealand Blood Service (NZBS)- Wellington Southern Community Laboratories (WSCL)- Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP)- Wellington Hospital (CCDHB)

Board of Trustees

John Elliot Chairman

Dr Ron Mackenzie Co-founder

Rob Siebers Treasurer

Mike LynchMember

Marion ClarkMember

Angela BrountsMember

Russell ColeLaboratory Quality Manager and Microbiology Specialist

Filipo FaigaBiochemistry Specialist

Navin KaranProgramme Manager and Microbiology Specialist

Philip WakemChief Executive Officer and Haematology Specialist

Vichet KhiengBiochemistry and LIS Specialist

PPTC Scientific Staff

PPTC Consultants

Dr Juliet ElvyClinical Microbiologist

Transfusion ScienceSusan Evans

Dr Julia PhillipsClinical Haematologist

PPTC EQA Consultants

BiochemistryFilipo Faiga

MicrobiologyNicky Beamish

HaematologyElizabeth Tough

Transfusion ScienceDan Gyles

Serology Sarah Brown

Anatomical PathologyDr Vladimir Osipov

HaematologyPhil Wakem

§ Improve the quality of work performed in medical laboratories by providing Laboratory Quality Management System Programmes (LQMS).

§ Provide training in the appropriate medical laboratory sciences.

§ Provide developmental assistance for medical laboratories and bloodtransfusion services of the Pacific Island Countries and Territories as wellas those of South East Asia.

Provided in one of six ways:

1) The PPTC Diploma in Medical Laboratory Science - Distance Learning.

2) Short term training courses of four to six weeks duration in NZ.3) Short-term training attachments for required skills.4) The PPTC External Quality Assessment Programme.5) PPTC in-country training with on-site workshops.6) The PPTC’s Laboratory Accreditation Programme (LQMS).

The PPTC’s Teaching And Training Programmes

The Medical Laboratory disciplines covered by the PPTC include:

Haematology Transfusion Science

Clinical Biochemistry Medical Microbiology

Infectious Disease Serology Histology

PPTCDiploma

Programme

The PPTC Diploma in Medical Laboratory Science

• Distance Learning Programme

• Launched in 2006 supported by WHO Pacific Open Learning Health Network (POLHN)

• 2016 supported by NZ-MFAT

• Offered to all students in the Western Pacific Region at no cost to the student or country’s Ministry of Health (MOH)

PPTC Diploma in Medical Laboratory ScienceModules 2 yr

DiplomaTheoretical component.

• Divided into sections• Each section consists of questions

both short answer and long answer.

Practicalwork books

Theory Examination

Laboratory Technology 1st Year CD ROM No Yes End of 1st Year

Haematology 1st Year CD ROM Yes Yes End of 1st Year

Biochemistry 1st Year CD ROM Yes Yes End of 1st Year

Microbiology 2nd Year CD ROM Yes Yes End of 2nd Year

Blood Transfusion 2nd Year CD ROM Yes Yes End of 2nd Year

Laboratory Quality Management 2nd Year CD ROM No Yes End of 2nd Year

To date…PPTC Diploma of Medical Laboratory Science:

113 graduates from 13 different countries.(Fiji, Tonga, Palau, Yap- Micronesia, Cook Islands, Marshall Islands, Pohnpei – Micronesia, Kosrae – Micronesia, Samoa, Tuvalu, Solomon Islands, Vanuatu and American Samoa)

2015 – 2016 Pohnpei’sGraduates

(Federated States of Micronesia)

43 students registered for the 2019- 2020 Diploma Programme:Country of Origin Student Numbers

ó American Samoa 4ó Federated States of Micronesia 10ó Fiji 3ó Papua New Guinea 5ó Samoa 9ó Solomon Islands 10ó Kiribati 2Total: 43 (25 males, 18 Females)

Of the 43 students, 3 were disqualified (1F, 2M) and 2 were exempt ( 1F, 1M) from part 1 of this cycle having completed the first year in a previous cycle.Final total of 38 students - currently enrolled in the 2019 – 2020 Diploma programme.

Current activity cycle : 2019-2020

PPTCShort Term

Training Programmes

Short Term Training Courses at the PPTC Centre

Four – Six weeks duration in selected disciplines for Pacific laboratory staff.

Funding is provided by NZAID, NZRC, NKT, WHO, the PPTC or through the country’s MOH

Courses offered throughout the year include:§ Health & Safety, and Infectious Diseases§ Laboratory Quality Management Systems§ Clinical Biochemistry § Effective Laboratory Management§ Haematology and Blood Cell Morphology§ Medical Microbiology § Blood Transfusion Science

Centre Based Training

Short-term training attachments to New Zealand laboratories

The New Zealand laboratory selected by the PPTC must be able to provide:

§ Skills that are required by the student.§ Continuous teaching and training without

disruption to the laboratory’s own workflow.§ A workload that is similar in size to the student’s

home laboratory.§ A selection of tests that the student would perform

in the home laboratory.

PPTCEQA

Programme

The PPTC External Quality Assessment Programme• 1985 - PPTC Regional External Quality Assessment [REQA] Programme

• 1990 - WHO collaborating centre

The PPTC External Quality Assessment Programme

§ The programme is funded by NZAID.(MFAT)

§ No cost to government laboratories in the South Pacific region.

§ Private registration is welcomed at a nominal cost.

§ 16 surveys are dispatched yearly covering five medical laboratory disciplines.

102 laboratories are currently enrolled in the 2019 EQA programme:

· 1 American Samoa (NZAID)· 1 Cook Islands (NZAID)· 4 Federated States of Micronesia (NZAID)· 10 Fiji· 2 Kiribati (NZAID)· 3 Laos (NZAID)· 2 Marshall Islands (NZAID)· 1 Nauru (NZAID)· 1 Niue (NZAID)· 1 Palau (NZAID)· 2 Papua New Guinea· 2 Samoa(NZAID)· 3 Solomon Islands (NZAID)· 2 Timor Leste (NZAID)· 2 Tonga (NZAID)· 1 Tuvalu (NZAID)· 3 Vanuatu (NZAID)· 1 Wallis & Futuna (NZAID)· 3 Bhutan (1 PPTC funded and 2 Private)· 56 Cambodia ( Self funded ) · 1 Maldives (Private)

Options to enrol in all disciplines or selected

disciplines

Six Disciplines include:HaematologyBiochemistryMicrobiology

Blood TransfusionInfectious Disease Serology

Histology

PPTC EQA Consultants

BiochemistryFilipo Faiga

MicrobiologyNicky Beamish

HaematologyElizabeth Tough

Transfusion ScienceDan Gyles

Serology Sarah Brown

Anatomical PathologyDr Vladimir Osipov

HaematologyPhil Wakem

Pacific AccreditationProgramme2016 - 2020

Pacific Accreditation Programme 2016 - 2020

§ Grant Funding Agreementbetween MFAT and the PPTC.

§ A 5 year mentoring and training programme 2016-2020.

§ Fully funded by MFAT.

§ Four selected Pacific countries.

The Activity Design is based on

Four Major Sections:• Accreditation Development (ISO15189)• Service Development• External Quality Assessment• Medical Laboratory Education

Purchasing & Inventory

Assessment

Information Management

Process Improvement

Facilities & Safety

Organization Personnel Equipment

Documents & Records

Process Control (QC & EQA) &

Specimen Management

Occurrence Management

Customer Service

Accreditation Development based on the 12 Quality System Essentials (QSE)

Service Development

q Strengthen and upgrade sections in Vanuatu, Solomon Islands, Samoa and Tonga. • Haematology• Biochemistry• Microbiology• Histo-pathology• Blood Transfusion Services• Specimen Reception

q Provision of equipment, reagents and training.

In Country Training

Audit Tool

Advanced and morecomprehensive SLIPTAprogramme modifiedfor those laboratoriesrecognised to have thecapacity and capabilityto reach InternationalStandard ISO15189Accreditation

Minimum standards fordistrict laboratories withlimited resources, capacityand capability.

Assessment scoring:A modified SLIPTA

WHO guide• More questions • Scoring values • Section expansion

This enables us to bettermonitor and effectivelyscore the progress madewith each consultationvisit and systematicallywork on sections.

2015 - 2018

41%

69%

43%

82%

54%

85%

68%

89%

75%

85%

62%

95%89%

85%

60%

97%

0%

100%

Pacific 1 Pacific 2 Pacific 3 Pacific 42015 2016 2017 2018

Haematology in the Pacific Its past continues to be its future

• Inadequate training (poor cell recognition, poor interpretative skill)• Poor staff management, by laboratory managers• Lack of Quality Culture• Lack of staff motivation to improve performance• Lack of priority or urgency for Laboratory issues• Lack of quality champions or drivers of Haematology excellence• Lack of Professional Development opportunities• Substandard equipment and poor quality staining techniques• Procurement issues: Lack of reagents and QC material• Lack of resident staff, experienced staff and knowledge transfer• Isolated and remote islands• Shortage of Pathologists and their input as Lab Directors• Qualified staff want to leave for NZ or Aust• Failure to appreciate the learning experience of REQA• Poor understanding of the clinical perceptions of the Haematology Laboratory

Challenges facing Haematology

EQA Errors A 75 year old female presents to the Haematology Clinic with ongoing lymphadenopathy. She has been referred by her GP for further investigation.

Haematology parameters: Haemoglobin: 144 g/L RBC: 4.70 x 10 12/L HCT: 0.451 MCV: 96.0 fL MCH: 30.6 pg MCHC: 319 g/L Platelets: 151 x 109/L WBC: 28.5 x 109/L

[1] Perform a manual differential reporting both percentages and absolute values. Percentage Value Absolute Value x109/L Neutrophils 12% 3.42 X10^9/L Lymphocytes 85% 24.23 X10^9/L Monocytes 1% 0.29 X10^9/L Eosinophils 2% 0.57 X10^9/L Basophils Blasts Promyelocytes Myelocytes Metamyelocytes Bands Atypical lymphocytes Plasma cells Hairy cells Other Nucleated red cells ……………….. / 100 white cells

[2] Comment on:

Red Cell Morphology: Red blood cell show normochromic normocytic

White Cell Morphology: White blood cell marked lymphocytosis. Atypical lymphocyte also noted In the blood film.

Platelet Morphology: Platelets show mild thrombocytopenia. [3] Construct a comment that is clinically useful Suggested of Acute Lymphocytic Leukemia (ALL) Bone marrow study to confirm. Remember: Report only what you see in the blood film. Do not conclude a diagnosis if your film findings do not support it.

Referee’ results: Chronic Lymphocytic Leukaemia

Diagnosis inconsistent with film findings.No blasts detected in differential

A 75 year old female presents to the Haematology Clinic with ongoing lymphadenopathy. She has been referred by her GP for further investigation.

Haematology parameters: Haemoglobin: 144 g/L RBC: 4.70 x 1012/L HCT: 0.451 MCV: 96.0 fL MCH: 30.6 pg MCHC: 319 g/L Platelets: 151 x 109/L WBC: 28.5 x 109/L

[1] Perform a manual differential reporting both percentages and absolute values. Percentage Value Absolute Value x109/L Neutrophils 17% 4.84x 109/L Lymphocytes 27% 7.69x 109/L Monocytes 2% 0.57 x 109/L Eosinophils 3% 0.85 x 109/L Basophils - - Blasts 50% 14.25 Promyelocytes - - Myelocytes - - Metamyelocytes - - Bands 1% 0.28 Atypical lymphocytes - - Plasma cells - - Hairy cells - - Other - - Nucleated red cells ……………….. / 100 white cells

[2] Comment on:

Red Cell Morphology: Normocytic Normochromic White Cell Morphology: Lymphocytosis, Neutropenia. Presence of smudge cells. Platelet Morphology: Slightly reduced with giant forms present. [3] Construct a comment that is clinically useful : Findings suggestive of Chronic Lymphocytic Leukemia. Suggest Flowcytometry.

Referee’ results: Chronic Lymphocytic Leukaemia.Predominance of small lymphocytes.Inconsistent with film findings.

Diagnosis inconsistent with differential

A 24 yr old female patient of Indian descent, is required by her insurance company to have a general medical checkup with accompanying routine blood tests. Haematology parameters: Haemoglobin: 121 g/L RBC: 5.50 x 1012/L HCT: 0.394 MCV: 71.6 fL MCH: 22.0 pg MCHC: 307 g/L Platelets: 308 x 109/L WBC: 7.8 x 109/L [1] Perform a manual differential reporting both percentages and absolute values.

Percentage Value Absolute Value x 109/L Neutrophils 51 % 3.9 x 109/L Lymphocytes 42 % 3.2 x 109/L Monocytes 1 % 0.07 x 109/L Eosinophils 6 % 0.46 x 109/L Basophils - - Blasts - - Promyelocytes - - Myelocytes - - Metamyelocytes - - Bands - - Atypical lymphocytes - - Plasma cells - - Hairy cells - - Other - - Nucleated red cells ……………….. / 100 white cells

[2] Comment on: Red Cell Morphology: Normochromic, Normocytic Red Blood Cells nucleoli is Present. White Cell Morphology: Normal White cells count, Normal in Morphology. Platelet Morphology: Normal in Number and Morphology. [3] Construct a comment that is clinically useful The blood Film finding do not support a final conclusion.

Referee’ results: Known Haemoglobinopathy( Heterozygous Hgb E)

Red cells show mild hypochromia, microcytosis.Not mentioned

Referee’ results:

Known Haemoglobinopathy( Heterozygous Hgb E)

Red cell show mild hypochromiamicrocytosisNot mentioned

A 65 year old patient attends the Haematology Clinic complaining of lethargy, and fever. He presents with anaemia, splenomegaly, hepatomegaly and lymphadenopathy. Haematology parameters: Haemoglobin: 98 g/L RBC: 3.02 x 10 12/L HCT: 0.321 MCV: 106.3 fL MCH: 32.5 pg MCHC: 305 g/L Platelets: 70 x 109/L WBC: 51.18 x 109/L [1] Perform a manual differential reporting both percentages and absolute values.

Percentage Value Absolute Value x 109/L Neutrophils 6 3.07 Lymphocytes 20 10.24 Monocytes 5 2.56 Eosinophils 1 0.51 Basophils Blasts Promyelocytes Myelocytes Metamyelocytes Bands Atypical lymphocytes 16 8.19 Plasma cells Hairy cells 52 26.61 Other Nucleated red cells ……………….. / 100 white cells

[2] Comment on: Red Cell Morphology: NORMOCYTIC NORMOCHROMIC WITH CRENATED CELLS White Cell Morphology: LEUCOCYTOSIS NOTED WITH MAINLY MONONUCLEAR CELLS. MOST CELLS HAVE FINE NUCLEAR CHROMATIN PATTERN AND HAIRY CYTOPLASMIC PROJECTIONS. OCCASSIONAL CELLS WITH DYSPLASTIC CHANGES Platelet Morphology: NORMAL [3] Construct a comment that is clinically useful FEATURES NOTED IS SUGGESTIVE OF HAIRY CELL LEUKEMIA SUGGEST BONE MARROW BIOPSY STUDIES

Referee’ results: Chronic Lymphocytic LeukaemiaPredominance of small lymphocytes

No Hairy cells seen

A 50 year old tourist visits an afterhours emergency clinic complaining of body ache, neck pain and rash on the upper chest.

Haematology parameters: Haemoglobin: 136 g/L RBC: 4.91 x 10 12/L HCT: 0.422 MCV: 85.9 fL MCH: 27.7 pg MCHC: 322 g/L Platelets: 349 x 109/L WBC: 4.98 x 109/L

[1] Perform a manual differential reporting both percentages and absolute values. Percentage Value Absolute Value x109/L Neutrophils 60 % 3.0 Lymphocytes 27 % 1,3 Monocytes 3 % 0,2 Eosinophils 9 % 0,5 Basophils Blasts Promyelocytes Myelocytes Metamyelocytes Bands 1 % 0,1 Atypical lymphocytes Plasma cells Hairy cells Other Nucleated red cells ……………….. / 100 white cells

[2] Comment on:

Red Cell Morphology: Normachromic Normocytic

White Cell Morphology: Mild Eosinophilia with Normal Morphology

Platelet Morphology: Normal in Number and Morphology [3] Construct a comment that is clinically useful

Result Suggestive of Possible Allergic Rash

Referee’ results: Normal Film

Absolute Eosinophils within the normal rangeEosinophil Count: 9% ( N: up to 4% , 0.5 x 109/L

A 4 year old male patient is admitted to hospital with severe anaemia and a raised temperature

Haematology parameters: Haemoglobin: 48 g/L RBC: 1.62 x 10 12/L HCT: 0.12 MCV: 77 fL MCH: 30 pg Platelets: 436 x 109/L WBC: 21.5 x 109/L [1] Perform a manual differential reporting both percentages and absolute values.

Percentage Value Absolute Value x 109/L Neutrophils 35 7,525 Lymphocytes 21 4,515 Monocytes 3 645 Eosinophils 1 215 Basophils Blasts 2 430 Promyelocytes Myelocytes 10 2,150 Metamyelocytes 15 3,225 Bands 10 2,150 Atypical lymphocytes Plasma cells 3 645 Hairy cells Other Nucleated red cells …7…………….. / 100 white cells

[2] Comment on: Red Cell Morphology: Generally microcytic but polychromatic macrocytic red cells also evident. White Cell Morphology: Leucocytosis with left shift; increased presence of myelocytes, metamyelocytes and band forms and toxic granulation Platelet Morphology: Generally normal with occasional giant platelet seen [3] Construct a comment that is clinically useful Evidence of Myelofibrosis

Referee’ results: Spherocytic Haemolytic Anaemiawith an underling reactive WBC picture

Incorrect absolute values

Referee’ results: Probable Fe Deficiency changes

No definitive conclusion

Referee’ results: Normal Film

Eosinophil Count: 5% ( N: up to 4% , 0.5 x 109/L)

A 28 year old female visits her Hospital’s Accident and Emergency Dept. She has returned home from Botswana and has an infected insect bite on her left leg which is inflamed and proving to be very painful. She has intermittent episodes of sweating , headache and diarrhea. Haematology parameters: Haemoglobin: 128 g/L RBC: 4.42 x 1012/L HCT: 0.393 MCV: 88.9 fL MCH: 29.0 pg MCHC: 326 g/L Platelets: 209 x 109/L WBC: 6.1 x 109/L [1] Perform a manual differential reporting both percentages and absolute values.

Percentage Value Absolute Value x 109/L Neutrophils 60 3.66 Lymphocytes 28 1.708 Monocytes 6 0.366 Eosinophils 6 0.366 Basophils Blasts Promyelocytes Myelocytes Metamyelocytes Bands Atypical lymphocytes Plasma cells Hairy cells Other Nucleated red cells ……………….. / 100 white cells

[2] Comment on: Red Cell Morphology: Normochromic Normocytic White Cell Morphology: Shows monocytosis with eosinophilia Platelet Morphology: Platelet is with reference range with normal morphology. [3] Construct a comment that is clinically useful Relative Eosinophilia and Monocytosis

Referee’ results: Normal Film

Eosinophil Count: 6% ( N: up to 4% , 0.5 x 109/L)Absolute count within the normal range.

Monocyte Count 6%( N: up to 9% , 1.0 x 109/LAbsolute count within the normal range.

A 28 year old female visits her Hospital’s Accident and Emergency Dept. She has returned home from Botswana and has an infected insect bite on her left leg which is inflamed and proving to be very painful. She has intermittent episodes of sweating , headache and diarrhea. Haematology parameters: Haemoglobin: 128 g/L RBC: 4.42 x 1012/L HCT: 0.393 MCV: 88.9 fL MCH: 29.0 pg MCHC: 326 g/L Platelets: 209 x 109/L WBC: 6.1 x 109/L [1] Perform a manual differential reporting both percentages and absolute values.

Percentage Value Absolute Value x 109/L Neutrophils 0.0 0.0 Lymphocytes 19 1.1 Monocytes 15 1.0 Eosinophils 65 3.9 Basophils 1 0.1 Blasts Promyelocytes Myelocytes Metamyelocytes Bands Atypical lymphocytes Plasma cells Hairy cells Other Nucleated red cells ……………….. / 100 white cells

[2] Comment on: Red Cell Morphology: Normochromic Normocytic erythrocytes seen with a mild poikilocytosis White Cell Morphology: Normal in counts but marked reactive eosinophilia and neutropenia seen. Platelet Morphology: Normal in counts with occasional large platelet and few giant platelet seen. [3] Construct a comment that is clinically useful Suggestive of an allergic response in terms of the marked reactive eosinophilia.

Referee’ results: Normal Film

65% EosinophilsNot detected by the Referee

Haematology Case study28yr old female,

ó 28yr old first time mother at 38 wks of gestationShe had tooth ache and significant gum bleeding 3 weeks prior and was seen at the dental clinic. After a week post extraction of the tooth she developed fever, dizziness and occasional pelvic pain, head ache and ear ache. She was admitted to the local District Hospital and her FBC results were as follows:

Date of admission: 10/9/19 FBC results:-óWCC 14.8ó Hgb 84 g/L, óMCV 87.8 fL, ó Platelet 29óWhite cell differential from the analyser could only read the lymphocytes at 7%

ó She was treated as a urinary tract infection and gestational thrombocytopenia based on her urine dipstick (actual result not provided) and FBC, so started on antibiotics, analgesics and fresh whole blood was given.

ó Her FBC results after three (3) units of fresh whole blood were as follows:

11.9.2019ó WCC 16.8 x 10 9/Ló Hgb 98 g/L, ó MCV 84.5 fL, ó Platelet 24, ó White cell differential from the analyser could only read the lymphocytes at 4.7%ó INR was 1.18. ó LFTs and RFTs unremarkable apart from hyponatraemia (Na 130 mmol/L), slightly increased ALP (194 U/L), and

slightly low albumin (32 g/L)

14.9.2019Admitted to Port Vila Hospital

She was assessed and found to be in no respiratory distress, afebrile, ó Pulse Rate of 98 ó BP – 110/60ó No ear discharge, no obvious gum enlargement, no lymphadenopathy, no organomegaly, unremarkable cardiac

and respiratory examination.ó There was a patchy petechial rash seen on her lips, neck, chest, back, abdomen and extremities. Bruises evident

at venepuncture site (anterior cubital fossa).

FBC:ó WCC 20.8 x 10 9/Ló RBC 3.44 x 10 12/Ló Hgb 97 g/Ló HCT 0.30ó MCV 87.7 fLó MCH 28.1 pgó MCHC 322 g/Ló Platelet 24 x 10 9/L

14.9.2019 Pathologists report:Blood film : predominantly normocytic normochromic RBCs and some NRBCs 5/ 100 white cells The white cell differential was as follows: ó Blast cells 8 %, ó Promyelocytes 24 %, ó Myelocytes 34 %, ó Metamyelocytes 20 %, ó Neuts 8 % ó Monocytes 6 %. The promyelocytes had large nuclei with some budding and irregular contours. 1-2 nucleoli seen in the nuclei. There were small fine granules in the cytoplasm. Platelet count was markedly reduced. A leukaemic process could not be excluded here. However, as it was a post whole blood transfusion, we wanted to see follow up FBC and blood films.Her labour was uneventful and she had a normal delivery on the 16/9/19, two days after her admission to the National hospital. Apart from that, she had some post-partum bleeding for which she was transfused 2 units of fresh whole blood.

Two days post transfusion, she developed rigors and chills. Her subsequent FBCs was as follows:

Pathologists Report:18.9.19 Blood film showed: normocytic RBCs with some NRBCs, red cell fragments and few bite cells. ó White cell differential is as follows: ó Blasts 17%, ó Promyelocytes 15%, ó Myelocytes 31%, ó Metamyelocytes 30%, ó Neuts 5%, ó Eosinophils 2%. The blast like cells look more like those of the myeloid series – Promyelocytic – large cells with large nuclei, one or two nucleoli, adequate cytoplasm fine granulation. The features are suspicious for Acute Promyelocytic leukaemia – AML, M3 variant) however second opinion is sought.

The patient is also managed by physicians and is on dexamethasone with an initial diagnosis of gestational thrombocytopenia.

Clinical Outcomeó Within 24hrs, the WBC accelerated to well over 100 x 10 9/Ló No treatment available to control the leukaemia. ó Patient developed DIC with a resulting fatal Haemorrhage.

PPTC, Wellington, NZ