The Intern At Work: Internal Medicine 10. Ask A Fellow: "Blasted Blasts" - Blasts in the peripheral blood smear
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Sep 9, 2018 Siraj Mithawani, hematology fellow and thrombosis scholar trained at McMaster, breaks down how to approach blasts on a peripheral smear. He defines myeloblasts versus lymphoblasts and lists causes to consider. Practical tips include verifying automated differentials, urgent signs that need action, recognizing APL as an emergency, and immediate tests and management steps to prioritize.
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What Blasts Actually Represent
- Blasts are the most immature myeloid or lymphoid cells seen in peripheral blood or bone marrow.
- Myeloblasts progress through promyelocyte, myelocyte, metamyelocyte, band to mature neutrophil, explaining why blasts signal interrupted maturation.
Always Rule Out Acute Leukemia First
- First priority when you see blasts is to rule out acute leukemia, including AML and ALL, and consider APL specifically.
- Also consider MDS, myelofibrosis, CML, leukemoid reactions, or post-chemotherapy/G-CSF recovery as alternative causes.
Always Get a Manual Smear Review
- If an automated differential reports blasts, request a manual differential or lab technologist review immediately.
- You can also inspect the peripheral smear yourself and escalate to the technologist or hematopathologist if uncertain.