A 60-year-old woman comes to the emergency department because of progressive fatigue and low grade fever for the last 2 weeks. She is from Mexico and is currently visiting her children in the United States. She has never been diagnosed with any chronic medical problems. However, she did receive a blood transfusion 20 years ago when she underwent right femur fracture repair after a motor vehicle accident. She denies tobacco, alcohol, or illicit drug use. Her temperature is 37.7 C (99.9 F), blood pressure is 130/76 mm Hg, and pulse is 90/min and regular. Her BMI is 27 kg/m². Physical examination reveals scleral icterus and non-tender rubbery lymph nodes bilaterally in the submandibular, anterior cervical, and axillary areas. Cardiopulmonary examination reveals a 2/6 ejection-type murmur at the left sternal border, and clear lungs. The liver edge is palpated 3 cm below the right costal margin, and the spleen tip is palpated on deep inspiration. There is no skin rash or peripheral edema. Laboratory results are as follows: Which of the following would most likely be present in this patient's peripheral blood smear?

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Quizplus · Accepted Answer

11ec193a_9614_67ed_853d_abe87452ec6d_MD0002_00 This patient's presentation is consistent with likely chronic lymphocytic leukemia (CLL), which accounts for nearly 30% of adult leukemias in the United States. Patients typically present with 'B' symptoms (e.g., recurrent fever, night sweats, weight loss, fatigue), anemia, thrombocytopenia, painless lymphadenopathy, and hepatosplenomegaly. Diagnosis is confirmed by peripheral smear showing > 5000/mL mature appearing small B lymphocytes and flow cytometry showing monoclonal B-cell characteristics (e.g., CD19, CD20, CD23). Chronic lymphocytic leukemia is associated with autoimmune hemolytic anemia (AIHA) in up to 11% of patients, especially those treated with purine analogs (i.e., fludarabine, cladribine, pentostatin). Autoimmune hemolytic anemia can be a presenting feature of unrecognized CLL. The partial RBC phagocytosis by the splenic macrophages causes excessive surface membrane loss and results in spherocytes. Diagnosis is confirmed by the direct antiglobulin (Coombs') test, which detects IgG or complement on the RBC surface. Treatment of AIHA involves corticosteroids to elicit disease remission and splenectomy if steroids are not effective. However, patients presenting with acute onset of severe hemolysis and symptomatic anemia require immediate packed RBC transfusion. (Choice A) Bite cells occur secondary to phagocytes extracting denatured hemoglobin precipitates (Heinz bodies) and are usually seen in α-thalassemia and G6PD deficiency. (Choice B) Schistocytes (fragmented RBCs) are typically seen in DIC, TTP/HUS, and traumatic hemolysis. (Choice C) RBC inclusions (e.g., Howell-Jolly bodies, basophilic stippling) are usually due to precipitates of nuclear or cytoplasmic fragments (e.g., ribosomes). Common causes include asplenia, thalassemia, or heavy metal poisoning (e.g., lead). (Choice E) Tear drop cells (dacryocytes) are usually seen in conditions associated with extramedullary hematopoiesis (e.g., myelofibrosis). Myelofibrosis can present with anemia, thrombocytopenia, and elevated WBC count. However, it tends to present with immature circulating cells in the peripheral smear without generalized lymphadenopathy. This patient's mature, predominantly lymphocytic leukocytosis makes this unlikely. Educational objective: Warm agglutinin autoimmune hemolytic anemia (AIHA) is a common complication of chronic lymphocytic leukemia (CLL) and is characterized by a positive direct antiglobulin (Coombs') test and spherocytes on peripheral smear. Treatment involves steroids followed by splenectomy in refractory patients. Patients with severe hemolysis and symptomatic anemia require packed RBC transfusion. __________ References: Chronic lymphocytic leukemia and autoimmunity: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/21242190) Chronic lymphocytic leukemia-associated autoimmune hemolytic anemia. (http://www.ncbi.nlm.nih.gov/pubmed/17577769)

A 60-Year-Old Woman Comes to the Emergency Department Because of Progressive