A 55-year-old woman comes to the office due to 3 months of night sweats. She has tried using a fan and sleeping without a comforter, but she continues to awaken several nights a week with bedsheets so drenched that she has to change them. During this time, she has unintentionally lost 5 kg (11 lb). The patient traveled to Vietnam with her church group 6 months ago and wonders if she may have "caught something." She took her antimalarial pills and received her pretrip vaccinations as recommended and has not had fevers. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37.4 C (99.4 F), blood pressure is 144/78 mm Hg, and pulse is 96/min. She has pale mucosa but no scleral icterus. There is no cervical lymphadenopathy. Cardiopulmonary examination is normal. A spleen tip is palpable when she exhales completely. Laboratory results are as follows: Which of the following is expected in this patient?

Question

A 55-year-old woman comes to the office due to 3 months of night sweats.  She has tried using a fan and sleeping without a comforter, but she continues to awaken several nights a week with bedsheets so drenched that she has to change them.  During this time, she has unintentionally lost 5 kg (11 lb).  The patient traveled to Vietnam with her church group 6 months ago and wonders if she may have "caught something."  She took her antimalarial pills and received her pretrip vaccinations as recommended and has not had fevers.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.4 C (99.4 F), blood pressure is 144/78 mm Hg, and pulse is 96/min.  She has pale mucosa but no scleral icterus.  There is no cervical lymphadenopathy.  Cardiopulmonary examination is normal.  A spleen tip is palpable when she exhales completely.  Laboratory results are as follows:  Which of the following is expected in this patient?

Quizplus · Accepted Answer

11ec25c8_d412_c70f_bc81_019193211327_MD0003_00 Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm caused by the BCR-ABL fusion gene. It is marked by a dramatic leukocytosis (often but not always >100,000/mm³), absolute basophilia, and a preponderance of early immature neutrophil precursors (promyelocytes, myelocytes). The leukocyte alkaline phosphatase (LAP) score can help differentiate CML from leukemoid reaction. In CML the neutrophils are cytochemically and functionally abnormal, so the LAP score is usually low. immature neutrophil precursors CML is often found on routine blood work in asymptomatic patients but may present with fatigue, weight loss, night sweats, or abdominal fullness (from splenomegaly). Thrombocytosis and anemia are common. (Choice A) In patients with an elevated red blood cell count, the absence of measurable erythropoietin in urine may suggest polycythemia vera. This patient is anemic. (Choice C) A positive acid-fast stain of the blood can be seen in disseminated tuberculosis (TB). Patients with disseminated TB can present with night sweats, fevers, and weight loss. However, disseminated TB is less likely to cause such a marked leukocytosis with immature neutrophil precursors. (Choice D) The Coombs test is used to detect antibodies on the surface of red blood cells as is often seen in autoimmune hemolytic anemia (AIHA). AIHA is common in some hematologic malignances (eg, chronic lymphocytic leukemia). This patient more likely has anemia due to her underlying CML. (Choice E) Malaria can be diagnosed using a Giemsa stain of the blood showing intraerythrocytic parasites. Although the patient recently traveled to Vietnam, her dramatic leukocytosis and cell differential would not be explained by malaria. It would also be uncommon for malaria manifestations to persist for several months. Malaria (Choice F) Auer rods are seen in many forms of acute myeloid leukemia (AML). AML tends to present relatively acutely with manifestations related to pancytopenia such as bleeding or infection. In addition, myeloblasts would be expected on peripheral smear examination. This patient has a more indolent presentation with thrombocytosis and leukocytosis. Auer rods Educational objective: Chronic myeloid leukemia (CML) is marked by dramatic leukocytosis, absolute basophilia, and a shift towards very early neutrophil precursor cells (promyelocytes, myelocytes). In CML, the leukocyte alkaline phosphatase score, a marker of neutrophil activity, typically is low. References: Chronic myeloid leukemia: 2014 update on diagnosis, monitoring, and management. (http://www.ncbi.nlm.nih.gov/pubmed/24729196)

A 55-Year-Old Woman Comes to the Office Due to 3