Question of the Week # 4

A 72 y/o man with hx of chronic alcoholism and smoking presents to your office with extreme fatigue. Denies any fever or weightloss or nightsweats. Vital signs were normal and physical examination is benign. Laboratory studies reveal CBC with hgb 9.5, wbc 10k with 35% neutrophils, 55% lymphocytes and 9% monocytes, platelets 90k. Basic metabolic panel is within normal limits.  A direct coombs test is negative. A peripheral blood smear is shown below.

Archer USMLE Step 3 QBANK

Most likely cause of  this patient’s  Anemia :

A) Vitamin B12 deficiency

B) Chronic Myeloid Leukemia

C) Chronic lymphocytic leukemia

D) Hypersplenism

E) Autoimmune Hemolysis

Copy Rights : USMLEGalaxy, LLC

9 Responses

  1. c

    • Stage O CLL

    • C

  2. e

  3. Ans. C

    The smear shows classic smudge cells. Smudge cells are fragile lumphocytes that get damaged and smudged during the smear preparation. Presence of Smudge cells in a patient like above with absolute lymphocytosis > 5000, is suggestive… of CLL. A peripheral blood flow cytometry should be obtained to confirm the diagnosis.

    CLL is staged based on lymphadenopathy, splenomegaly, anemia and thrombocytopenia. Presence of anemia classifies CLL as stage IV where as thrombocytopenia makes it a Stage V. However, this anemia and thrombocytopenia can occur in a CLL patient because of autoimmune mechanisms and may not be directly secondary to CLL. A direct coombs test must always be obtained to rule out this possibility and hence, to avoid mis-staging of CLL. If direct coomb’s is positive, a Bone marrow biopsy should be done to check if there is a CLL infiltration of marrow additionally contributing to Anemia. If there is CLL infiltration of marrow possibly causing anemia, that suggests Stage IV CLL. Some of the criteria for therapy in CLL are a) Anemia b) Thrombocytopenia c) Presence of bulky disease d) severe fatigue e) lymphocyte doubling time less than 6 months. .

    CLL need not be treated unless the above criteria for treatment are present. This patient’s CLL belongs to Rai Stage V in that he has thrombocytopenia. This patient requires treatment.

    Choice B is not correct since the CBC is consistent with a lymphoproliferative disorder like CLL not a myeloproliferative disorder like CML. In CML, you expect to see proliferation of myeloid lineage with an increase in immature granulocytes, neutrophils and especially, an absolute increase in basophils and eosinophils.

    Choice A and D are incorrect as they do not explain the lymphocytosis or smudge cells.

  4. this is a great smear
    beautiful smudge !

  5. and treatment would be Fludarabin 70?

  6. why is direct coombs test negative here? i could not get it.

  7. Hywrslpeenism

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