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 10 3 /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 x10 3 /L WBC35 x10 3 /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 Acid4.7 mg/dL Albumin4.2 g/dL Total Protein7.7 g/dL AST33 U/L ALT27 U/L Alkaline Phosphatase97 U/L LDH650 U/L IgG (quantitative)1560 mg/dL IgA (quantitative)358 mg/dL IgM (quantitative)152 mg/dL

Peripheral smear

Flow cytometry TdT0 CD10 CD266 CD394 CD492 CD593 CD735 CD82 CD100 CD1529 CD190 CD200 CD2992 CD331 CD340 CD384 CD4599 CD567

Skin Biopsy

EM of the lymphocytes

Staging System for Chronic Lymphocytic Leukemia StageLymphocy tosis Lymphaden opathy Hepatome galy or Splenome galy Hemoglo bin (g/dL) Platelet s (x 10 3 /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