Case 363: 72 y/o man with diffuse skin erythema and

lymphocytosis

History

• A 72 year-old man consulted a hematologist after the incidental finding of a WBC count of 25.0 x 103/uL (25,000/uL) by his family physician. A peripheral blood smear had shown 83% mononuclear cells somewhat larger than well-differentiated lymphocytes with cleaved nuclei and occasional prominent nucleoli. He had erythematous and thickened skin (erythroderma) affecting his chest, back, groin, and to a lesser extent, his face and arms. There was no significant lymphadenopathy or hepatosplenomegaly

The patient

• CBC: Hgb: 14.2 g/dL• Hct: 42.5%• RBC Indices:• MCV: 91.2 fL• MCH: 30.5 pg• MCH: 33.4%• RDW: 14.1%• Platelets: 285 x103/L• WBC 35 x103/uL• Differenti• Segs: 4,900/µL• Bands: 700/µL• Lymphocytes: 28,200/µL• Monocytes: 1,400/µL• Basophils: 0/µL• Eosinophils: 0/µL

• CHEMISTRIES:• Uric Acid 4.7 mg/dL• Albumin 4.2 g/dL• Total Protein 7.7 g/dL• AST 33 U/L• ALT 27 U/L• Alkaline Phosphatase 97 U/L• LDH 650 U/L• IgG (quantitative) 1560 mg/dL• IgA (quantitative) 358 mg/dL• IgM (quantitative) 152 mg/dL

Peripheral smear

Flow cytometry• TdT 0• CD1 0• CD2 66• CD3 94• CD4 92• CD5 93• CD7 35• CD8 2• CD10 0• CD15 29• CD19 0• CD20 0• CD29 92• CD33 1• CD34 0• CD38 4• CD45 99• CD56 7

Skin Biopsy

EM of the lymphocytes

Staging System for Chronic Lymphocytic Leukemia

Stage Lymphocytosis

Lymphadenopathy

Hepatomegaly or Splenomegaly

Hemoglobin (g/dL)

Platelets (x 103/μL)

RAI System

0 + - - ≥ 11 >100

I + + - ≥ 11 >100

II + ± + ≥ 11 >100

III + ± ± < 11 >100

IV + ± ± Any <100

BINET System

A + ± ± ≥ 10 >100

B + ± ± ≥ 10 >100

C + ± ± < 10 <100