A 63-year-old man comes to the office for follow-up after a recent emergency department (ED) visit. The patient has had several months of mild shortness of breath and cough with clear sputum production. Ten days ago, he came to the ED due to worsening cough, shortness of breath, and wheezing. He was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease and was prescribed inhaled bronchodilators, empiric antibiotics, and a 7-day course of oral prednisone. His respiratory symptoms have since improved. The patient has no other medical problems. Current medications are inhaled tiotropium and as-needed albuterol. He has smoked a pack of cigarettes daily for 34 years, but now smokes 5 or 6 cigarettes daily. The patient drinks alcohol occasionally and does not use illicit drugs.
Temperature is 36.7 C (98 F) , blood pressure is 110/80 mm Hg, pulse is 78/min, and respirations are 16/min. Pulse oximetry shows 97% on room air. Examination reveals several discrete, firm, and nontender lymph nodes in cervical and axillary regions. The lungs are clear to auscultation but expiration is prolonged. Heart sounds are normal. The abdomen is soft and nontender. Liver edge is palpable 2 cm below the right costal margin, and mild splenomegaly is present.
Laboratory results are as follows:
Leukocyte count at the time of his ED evaluation was 22,000/mm³.
Which of the following is the best next step in management of this patient's leukocytosis?

Question

A 63-year-old man comes to the office for follow-up after a recent emergency department (ED) visit. The patient has had several months of mild shortness of breath and cough with clear sputum production. Ten days ago, he came to the ED due to worsening cough, shortness of breath, and wheezing. He was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease and was prescribed inhaled bronchodilators, empiric antibiotics, and a 7-day course of oral prednisone. His respiratory symptoms have since improved. The patient has no other medical problems. Current medications are inhaled tiotropium and as-needed albuterol. He has smoked a pack of cigarettes daily for 34 years, but now smokes 5 or 6 cigarettes daily. The patient drinks alcohol occasionally and does not use illicit drugs.
Temperature is 36.7 C (98 F) , blood pressure is 110/80 mm Hg, pulse is 78/min, and respirations are 16/min. Pulse oximetry shows 97% on room air. Examination reveals several discrete, firm, and nontender lymph nodes in cervical and axillary regions. The lungs are clear to auscultation but expiration is prolonged. Heart sounds are normal. The abdomen is soft and nontender. Liver edge is palpable 2 cm below the right costal margin, and mild splenomegaly is present.
Laboratory results are as follows:

Leukocyte count at the time of his ED evaluation was 22,000/mm³.
Which of the following is the best next step in management of this patient's leukocytosis?

Quizplus · Accepted Answer

This patient's persistent lymphocytosis is likely due to chronic lymphocytic leukemia (CLL), the most common adult leukemia in Western countries. Most patients are asymptomatic at diagnosis and are discovered to have CLL after routine blood work shows absolute lymphocytosis (>5,000/mm³); lymphocyte count is often elevated >100,000/mm³. Other common findings include: ³ ³ Lymphadenopathy (50%-90%) - localized (most commonly cervical, axillary, and supraclavicular) or generalizedSplenomegaly (25%-55%)Hepatomegaly (15%-25%)Mild neutropenia, anemia, thrombocytopenia Lymphadenopathy (50%-90%) - localized (most commonly cervical, axillary, and supraclavicular) or generalized Lymphadenopathy (50%-90%) - localized (most commonly cervical, axillary, and supraclavicular) or generalized Splenomegaly (25%-55%) Splenomegaly (25%-55%) Hepatomegaly (15%-25%) Hepatomegaly (15%-25%) Mild neutropenia, anemia, thrombocytopenia Mild neutropenia, anemia, thrombocytopenia The diagnosis of CLL is confirmed by peripheral blood smear and flow cytometry of the peripheral blood with immunophenotypic analysis of circulating lymphocytes. Bone marrow aspirate and biopsy and lymph node biopsy are not required for diagnosis (Choices B and D). However, lymph node biopsy may sometimes be performed in those with suspected small lymphocytic lymphoma (similar features to CLL but no absolute lymphocytosis or cytopenias) or malignant transformation. peripheral blood smear (Choice A) Although CT scan of the chest, abdomen, and pelvis is likely to demonstrate lymphadenopathy, imaging is not typically used to stage CLL. Staging typically takes into consideration lymphocytosis, anemia, thrombocytopenia, and physical examination findings (eg, lymphadenopathy, splenomegaly, hepatomegaly). (Choice C) This patient has persistent absolute lymphocytosis as well as hepatosplenomegaly and lymphadenopathy; diagnostic evaluation should not be delayed. In addition, peripheral blood flow cytometry is minimally invasive. Educational objective: Chronic lymphocytic leukemia typically presents with absolute lymphocytosis (>5,000/mm³) in an asymptomatic older patient. Physical examination often reveals lymphadenopathy, splenomegaly, and/or hepatomegaly. Diagnosis is confirmed with peripheral blood smear and peripheral blood flow cytometry. Lymph node and bone marrow biopsies are not required. ³ __________

A 63-Year-Old Man Comes to the Office for Follow-Up After