Case 240 -- Fatigue, Easy Bruising, and Cellulitis

Contributed by Octavia Graur, MD, PhD
Published on line in July 2000


The patient is a 51-year-old man who presented with fatigue, easy bruising, and a left lower leg cellulitis. There was also a reported two year history of pancytopenia.


A complete blood count revealed pancytopenia (Table 1). A manual white blood cell differential count and a review of peripheral blood smear was performed (Table 2). The red blood cell morphology showed mild anisocytosis, occasional Burr cells, mild poikilocytosis (Figure 1). The white blood cells were decreased in number ; there were occasional cells with moderately abundant, weakly basophilic cytoplasm, with irregular "hairy" projections, an ill-defined cell outlines, an eccentric, oval shaped nucleus, with finely dispersed chromatin, and inconspicuous nucleoli (Figure 2). The platelets were slightly decreased.

The marrow aspirate smears were very dilute (Figure 3) and inadequate for interpretation.

The marrow biopsy was hypocellular with a cellularity of approximately 30% (Figure 4). There was an extensive interstitial lymphoid infiltrate that occupied most of the cellular areas (Figure 5). The majority of lymphocytes were small to intermediate in size with condensed chromatin and moderate amounts of cytoplasm (Figure 6). The myeloid-erythroid ratio was not evaluable as very few erythroid and myeloid cells were identified. Megakaryocytes were present, but in decreased numbers. Reticulin staining demonstrated a moderate to marked increase in fibers (Figure 7). In an attempt to characterize the bone marrow infiltrate, a tartrate resistant acid phosphatase stain was performed on a touch preparation, and showed occasional positive cells (Figure 8). In order to further characterize the lymphocytic infiltrate, paraffin section immunohistologic studies were performed on the bone marrow biopsy. Most of the cells stained positive with CD20 (Figure 9), showing only occasional scattered positive CD3 cells (Figure 10)


Flow cytometric immunophenotypic studies revealed a CD10 negative, CD5 negative, monoclonal lambda B-cell population that was also positive for CD103, CD25 as well as bright CD22 and CD11c. (Figures 11, 12, 13 and 14)


No cytogenetic abnormalities were detected.



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