Case study (18)- Chronic lymphoid leukemia 

History and clinical signs and symptoms 

A 45-year-old man was diagnosed with indolent chronic lymphoid leukemia 6 years before. 

Quite recently night sweating and lymphadenopathy in the cervical region have developed. 

The patient returned to his scheduled control visit. 

Physical signs and symptoms include fatigue, the spleen is enlarged. 

Laboratory Investigations 

1. Hematologic findings 

RBC:5.28X 106/μL (4-5.5 X 106/μL) 

HGB: 135 g/dL (120-174 g/dL) 

HCT: 43.5 % (36-52%)

MCV: 82.4 fL (76–96 fL)

MCH: 25.6 pg (27-32 pg)

MCHC: 310 g/L (300-350 g/L) 

RDWsd:30.4 fL (20-42 fL) 

RDWcv: 11.9 % (0-16 %) 

WBC: 118.4 X103/ μL (5–10 X 103/ μL) 

Neutrophils: 4.50 X 103/μL (2-7.5 X 103/μL) 

Lymphocytes: 93.43 X 103/μL (1.08–3.17 X 103/μL) 

Monocytes: 11.60 X 103/μL (0.15-0.7 X 103/μL) 

Eosinophils: 0.47 X 103/μL (0-0.5 X 103/μL) 

Basophils: 8.41 X 103/μL (0-0.15 X 103/μL) 

Neutrophils %: 3.8 % (40-75 %) 

Lymphocytes %: 78.9 % (14.76-45.4 %)

Monocytes %: 9.8 % (3-7 %)

Eosinophils %: 0.4 % (0-5 %) 

Basophils %: 7.1 % (0-1.5 %) 

PLT: 199 X 103/μL (150-400 X 103/μL) 

Warning Flags D, Morphological flags GL 

Interpretation 

The WBC DIFF scattergram is abnormal, lymphocytes and monocytes are not separated.

Thus the instrument was unable to differentiate a significant portion of the WBC population (see warning flag “D”). 

Based on the WBC DIFF and BAS scattergrams the presence of abnormal cells is highly suspected. 

Beside abnormal scattergram characteristics, the WBC count is very high and percentile distributions’ are pathologic. 

Linearity flag “ * ” indicates that WBC counts are out of the linearity range. 

Morphological flags ‘G’ and ‘L’ are indicative of immature granulocytes and atypical lymphocytes. 

Blasts, immature and abnormal cells cannot be distinguished reliably with the HumaCount 5L system. 

Due to their altered cytoplasmic and membrane structure, they can mimic other cells often falsely elevating basophil, and monocyte counts can be seen in this example when comparing results to those of microscopic evaluation. 

Based on the histograms, the red cell (RBC) and platelet (PLT) populations are clearly defined and well separated. 

The RBC parameters are without any pathologic alterations. 

The PLT count is slightly below the lower normal limit.

The assessment of a peripheral blood smear is essential due to the high WBC count, undifferentiated WBC populations, and warning flags.

Peripheral blood smear

Peripheral blood smear characterized by variant lymphocytes corresponds to the clinical diagnosis.

The relative prevalence of the WBCs was as follows: neutrophil cells (5.5%), lymphocytes (25.5%), monocytes (2.7%), variant (enlarged) lymphocytes (65.5%) and blasts (0.9%) and smudge cells.

2. Other laboratory findings

Diagnosis