A 50-year-old Iraqi man presented with splenomegaly and pyrexia of unknown origin. A bone marrow aspirate was done as part of the investigations and unexpectedly showed Plasmodium falciparum parasites. Malaria had not been suspected as this condition is now rare in Iraq but it subsequently transpired that the patient had recently visited Pakistan.The gametocytes that are observed in the bone marrow differ from those that are observed in the blood, being less mature [1]. The immature gametocytes that are seen include some that are sail-shaped, spindle-shaped or oval (top) rather than the crescent-shaped macrogametocyte and sausage-shaped microgametocyte that are usually observed in the blood. This reflects the fact that gametocytes develop in the internal organs, including the bone marrow, rather than in the circulating blood. Photographs of the bone marrow of this patient show sail-shaped (left), spindle-shaped (centre) and oval (right) immature gametocytes. Some mature gametocytes were also present.

A 4-year-old boy presented with pallor, visual problems and recurrent multiple bilateral renal stones that had been unresponsive to (non-specific) medical treatment. He had seen a number of physicians over a period of two years without a diagnosis being made. He was found to have pancytopenia, the blood count showing: white cell count 3.1 3 10 9 /l, hemoglobin concentration 86 g/l, and platelet count 102 3 10 9 /l. A bone marrow aspirate was performed to investigate the pancytopenia and revealed numerous clear cystine crystals, apparently free and within macrophages (images). This rare lysosomal storage disease is readily diagnosed from a bone marrow aspirate because of the presence of distinctive non-staining crystals. The crystals have straight edges and, when seen end on, are hexagonal (lower image).

Diagnosis of acute leukemia in Iraq is mainly dependent on the personal experience of the laboratory physician. Local guidelines in this field were never proposed and the international guidelines are very difficult to apply as the only available techniques include morphology of peripheral blood and bone marrow specimens plus very limited immunohistochemistry CD markers and PCR testing for BCR-ABL oncogene only, therefore the aim for diagnosis, classification and subclassification of acute leukemia in this country should be that of diagnosis and lineage assignment that serves a clear therapeutic goal.Having been working in the field of laboratory hematology since 2003 in the major teaching hospitals in Baghdad, I found that the following scheme is the available useful option:Acute leukemia should be classified on the basis of FAB group, but using a cut-off point of 20% blast cells, as proposed in the WHO classification [1]. Acute myeloid leukemiaWith Romanowsky stain morphology AML-M2, M3, M4, M5b and M6 can be recognized readily.By adding few special stains such as Sudan black B (SBB) [2] (and not myeloperoxidase as SBB has a little more sensitivity in detecting myeloblasts which is the crucial point), plus a non-specific esterase stain as -naphthyl acetate esterase it becomes possible to recognize AML-M1 and most cases of AML-M5a [3].The AML cases that cannot be distinguished by morphology and cytochemistry, specifically M0 and M7, for which the presence of myeloid dysplasia in the former and the cytoplasmic blebs in the latter may give a hint for the probable diagnosis, however there is still the need for more positive diagnostic technique and as the flow cytometry immunophenotyping is not available then the use of a limited number of CD markers study by immunohistochemistry to identify the lineage of acute leukaemia is the option, these include CD33, anti-myeloperoxidase and CD41.Rare types of AML like M5c require high degree of morphology experience, in which malignant cells appearance is reminiscent of tissue histiocytes [4].There is still a small proportion of cases that would be only certainly diagnosed after the response to treatment as in rare forms of AML-M3v [5].

A variety of types of inclusions are seen in the neoplastic cells of multiple myeloma (plasma cell myeloma). Among these, crystalline inclusions resembling Auer rods are uncommon. This 47-year-old Iraqi woman presented with back pain and anemia (haemoglobin concentration 100 g/l). A diagnosis of immunoglobulin (Ig) Gj myeloma with Bence-Jones proteinuria was made [1]. The bone marrow was heavily infiltrated by cytologically abnormal plasma cells including multinucleated and nucleolated cells (left). In addition the majority of neoplastic cells contained azurophilic cytoplasmic crystals. A further curious feature (right) was the presence of mitotic figures within crystal-containing myeloma cells, the presence of the crystals serving to identify the cells in mitosis as myeloma cells.Auer-rod like inclusions in myeloma cells have been described in association with IgG, IgA, IgM and light chain only (kappa) myeloma[2]. They are generally[2], but not invariably [3], associated with paraproteins with kappa light chains and are more often associated with IgA myeloma. They do not represent immunoglobulin but rather are of lysosomal origin, being positive for alpha naphthyl acetate esterase, beta glucuronidase and acid phosphatase [4]. There is an association with adult Fanconi syndrome due to deposition of crystals in renal tubules [2]. Myeloma cells can also contain crystalline inclusions that do represent immunoglobulin but these differ from Auer-rod like inclusions in that they stain pale pink on Romanowsky stains, rather than being azurophilic.

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