USMLE Forums banner
1 - 3 of 3 Posts

·
Registered
Joined
·
4,342 Posts
Discussion Starter · #1 ·
A 56-year-old man presents to his physician complaining of severe fatigue. He began to feel increasingly tired about 6 months ago, but believes that his fatigue has been worsening over the past 3 weeks. He also notes that he has had a nonproductive cough for about 2 weeks, and has experienced several episodes of drenching night sweats. On examination, he has several large bruises on his extremities but recalls no injuries. Abdominal examination reveals massive enlargement of both the liver and the spleen, without any lymphadenopathy.

Laboratory tests show:
WBC count 12,000/mm3
Neutrophils 58%
Eosinophils 7%
Lymphocytes 30%
Monocytes 0%
Basophils 5%
RBC count 3.0/mm3
Hemoglobin 7.5 mg/dL
Platelet count 18,000/mm3
Peripheral blood smear reveals irregular nuclei and cell membranes, as well as cytoplasmic projections.

What is the patient’s most likely diagnosis?
(A) Acute lymphocytic leukemia
(B) Hairy cell leukemia
(C) Idiopathic thrombocytopenic purpura
(D) Infectious mononucleosis
(E) Nodular sclerosing Hodgkin’s lymphoma
 

·
Registered
Joined
·
187 Posts
"Cytoplasmic projections" --> hairy cell leukemia, for USMLE purposes, without second thought.

Hairy cell leukemia (CLL in general -- hairy cell leukemia is a special type of CLL) is one of the two most notorious entities for causing massive hepatosplenomegaly (the other one is leishmaniasis, which causes only splenomegaly; storage disease etc are other causes, but this is not my point here... my point is to have leishmaniasis in mind in a middle-aged pt with a very large spleen).

Constitutional symptoms (fever, malaise, night sweats -- in the case of Hodgkin's diesease they are called beta symptomatology) are common. The bruises found in this patient is apparently due to low platelet count, which in turn is due to infiltration of the bone marrow by the leukemic cell line. Low RBC count comes to support this statement.

Nodular sclerosis HD is found primarily in young adults; ALL is found almost exclusively in children (acute exacerbation in CLL patients is called blast crisis, but this entity is far more common in CML). Infectious mononucleosis is not common in a pt 56yo and, although it could cause inversion of the WBC type, it doesn't affect RBCs and PLTs. ITP would affect only the PLT cell line and in this case the spleen is usualy NOT enlarged, although PLT destruction occurs in this organ (bear in mind that ITP may sometimes be a manifestation of a hematologic malignancy, though).
 

·
Registered
Joined
·
187 Posts
In my previous post I forgot to mention the association of hairy cell leukemia with the expression of Tartrate-resistant acid phosphatase (TRAP).

In order to remember this correlation, I have made an imaginary face in my mind: a guy with messy hair (let's say Einstein)... his HAIR is a TRAP for particles & stuff. :p
 
1 - 3 of 3 Posts
Top