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This 6 year old white male presenting with a bump on his neck that was initially
thought to represent an infection and a course of amoxicillin was started. Despite
Peripheral Blood
WBC
15.2 10x9/L
RBC
4.45 10x12/L
Hgb
12.5 g/dL
Hct
36.6 %
MCV
82.3 fL
MCH
28.1 fL
MCHC
34.1 g/dL
RDW
11.9 %
PLT
254 10x9/L
Retic
Retic
antibiotic therapy the bump increased in size over the past week. A peripheral blood
smear at the referring hospital was interpreted as having a question of increased
blasts. Bone marrow to rule out leukemia.
Percentage
Abs. No.
Polys
11 %
1.67
Lymphs
38 %
5.78
Atyp. Lymphs
45 %
6.84
Monos
5%
0.76
Eos
1%
0.15
Bands
Baso
Blasts
Promyelos
Myelos
Metamyelos
NRBC/100 WBC
BONE MARROW:The marrow aspirate smear is adequate for interpretation with cellular
spicules seen. Four aspirate smears and zero touch imprints reviewed.
Bone Marrow Differential
Blasts
2.3 %
Promyelos
1.5 %
Myelos
10.2 %
Metamyelos
6.4 %
Bands
9%
PMN
10.2 %
Eos Myelo/Metas
0.8 %
Eos Bands
Eos Segs
1.5 %
Basos
0.4 %
Monos
5.3 %
Pronormos
3.8 %
Normos
24.4 %
Lymphos
24.1 %
Plasma Cells
0.4 %
Others
Myeloid:Erythroid Ratio 1.7
Total # of cells counted: 300
Atypical lymphocytes were seen upon scanning. Histiocytes with cytoplasmic debris as well as
many naked nuclei are noted.
Atypical lymphocytes :
naked nuclei
Results: Cell suspension immunophenotypic studies were performed on the bone marrow
aspirate and one region was analyzed.
Region 1 represents the small non-complex cells (52% of the events).
VIABILITY: 99%
B Cells
Antigen
Usual Specificity
% Positive
Kappa +
B Cell Subset
Lambda +
B Cell Subset
Kappa:Lambda Ratio
0.7
CD19+
B Cell
11
CD19+/CD5+
B Cell Subset
CD20+
B Cell
CD10+ (Calla)
B Cell Subset
T Cells
Antigen
Usual Specificity
% Positive
CD2+
T Cell
84
CD3+ Total
T Cell
78
CD5+/CD19-
T Cell
74
CD7+
T Cell
72
CD4+/CD8-
T Helper
13
CD8+/CD4-
C Cytotoxic/Suppressor
63
CD4+/CD8+
T Cell Subset
CD4:CD8 Ratio
T Helper:Suppressor Ratio
0.2
CD16,CD56+/CD3+
T Cell Subset
CD16,CD56+/CD3-
NK Cells
Myeloid
Antigen
Usual Specificity
% Positive
CD15+
Myeloid
CD34+
Stem Cell
Additional Antibodies
Antigen
Usual Specificity
% Positive
CD45+
Leukocytes
96
HLA DR+
B, Myeloid, Activated T
78
TdT+
Lymphoblasts (Myeloblasts)
Cyto CD3+
T Cells
76
CD22+
Interpretation:
Flow cytometric immunophenotypic studies reveal an increased population of CD3+ Tlymphocytes (78%). This poulation also showed a low CD4:CD8 ratio (0.2) and strong
expression of HLA-DR antigen (78%). These findings are consistent with infectious
mononucleosis.
FINAL DIAGNOSIS:
Part 1: PERIPHERAL BLOOD MILD LEUKOCYTOSIS (lymphocytosis). (see comment)
Part 2: BONE MARROW ASPIRATE TRILINEAGE MATURATION AND MILD LYMPHOCYTOSIS.
Comment:
The morphological findings are commonly associated with EBV infection (45% atypical
lymphocytes).
Contributer's Note:
This case was chosen because of the classic hematologic findings and the opportuniy to perform
flow cytometric studies on this bone marrow aspirate. (Flow cytometry was performed at no
charge to the patient and used for educational purposes only.) Although the Epstein Barr virus
infects the B-lymphocytes, it results in an expansion of the CD8+ T-lymphocyte population in the
peripheral blood. This population of cells also demonstrates increased expression of HLA-DR
antigen which is consistent with in vivo activation(Clin exp Immunol 1991;83:447-451). These
findings were confirmed in the bone marrow aspirate in this case. We were unable to review the
peripheral blood slide from the outside hospital to confirm the presence of blast-like cells.