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Case study (19)- Chronic Lymphocytic (B-Cell) leukemia

Case study (19)- Chronic Lymphocytic (B-Cell) leukemia

Case study (19)- Chronic Lymphocytic (B-Cell) leukemia 

History and clinical signs and symptoms 

A 55-year-old woman was diagnosed with chronic B-cell (B-CLL) 2 years ago. 

The patient is regularly treated with a standard chemotherapeutic regime. 

Now she returned for the next course of therapy. 

Lymphadenopathy was developed in the retroperitoneal region. 

Mild hepatosplenomegaly was also present. 

Laboratory Investigations 

1. Hematologic findings 

RBC:3.10 X 106/μL (4-5.5 X 106/μL) 
HGB: 104 g/dL (120-174 g/dL) 
HCT: 34.9 % (36-52%)
MCV: 112.5 fL (76–96 fL)
MCH: 33.6 pg (27-32 pg)
MCHC: 299 g/L (300-350 g/L) 
RDWsd:61.0 fL (20-42 fL) 
RDWcv: 15.5 % (0-16 %) 
WBC: ----- X103/ μL (5–10 X 103/ μL) 
Neutrophils: ----- 103/μL (2-7.5 X 103/μL) 
Lymphocytes: ----- 103/μL (1.08–3.17 X 103/μL) 
Monocytes: ----- 103/μL (0.15-0.7 X 103/μL) 
Eosinophils: ----- 103/μL (0-0.5 X 103/μL) 
Basophils: ----- 103/μL (0-0.15 X 103/μL) 
Neutrophils %: ----- % (40-75 %) 
Lymphocytes %: ----- % (14.76-45.4 %)
Monocytes %: ----- % (3-7 %)
Eosinophils %: ----- % (0-5 %) 
Basophils %: ----- % (0-1.5 %) 
PLT: 189 X 103/μL (150-400 X 103/μL) 
Warning Flags O , Morphological Flags G, Interpretive Flags Anemia?, Macrocytic RBC?, Hypochromic? 


The RBC and PLT histograms are normal in shape and well separated. The red cell (RBC) population is low in size. 

The low RBC count indicates anemia (flagged). 

The elevated RDWsd indicates the heterogeneity in RBC size (anisocytosis). The mean cell hemoglobin concentration 

(MCHC) is below the lower level of normal in the majority of RBCs. The anemia is flagged as macrocytic and hypochromic. 

The instrument was unable to provide a WBC count but the DIFF and BAS scattergrams clearly show the presence of cells. 

The WBC DIFF scattergram indicates a confluent population; the Warning Flag “O” is also present indicating that cell count is over the upper limit of the linearity range. Therefore, the sample was diluted 2-fold in saline and re-measured. 

Please, note that the WBC count should be multiplied by a factor of 2 and the real numerical counts should be around 2fold of the displayed values. 

CBC Results After Sample Dilution 
RBC:1.57 X 106/μL (4-5.5 X 106/μL) 
HGB: 52 g/dL (120-174 g/dL) 
HCT: 17.8 % (36-52%)
MCV: 112.8 fL (76–96 fL)
MCH: 33.3 pg (27-32 pg)
MCHC: 295 g/L (300-350 g/L) 
RDWsd:61.2 fL (20-42 fL) 
RDWcv: 15.5 % (0-16 %) 
WBC: 82.10 X103/ μL (5–10 X 103/ μL) 
Neutrophils: 2.22 X 103/μL (2-7.5 X 103/μL) 
Lymphocytes: 66.67 X 103/μL (1.08–3.17 X 103/μL) 
Monocytes: 10.67 X 103/μL (0.15-0.7 X 103/μL) 
Eosinophils: 0.16 X 103/μL (0-0.5 X 103/μL) 
Basophils: 2.38 X 103/μL (0-0.15 X 103/μL) 
Neutrophils %: 2.7 % (40-75 %) 
Lymphocytes %: 81.2 % (14.76-45.4 %)
Monocytes %: 13.0 % (3-7 %)
Eosinophils %: 0.2 % (0-5 %) 
Basophils %: 2.9 % (0-1.5 %) 
PLT: 104 X 103/μL (150-400 X 103/μL) 

Morphological Flags G, Interpretive Flags Leukocytosis ?, Monocytosis ?, Lymphocytosis ?, Basophilia ?, Anemia?, Macrocytic RBC?, Hypochromic? 
According to the diluted sample, the WBC count is extremely high (about 160 G/L). 

The overwhelming majority of the WBCs are lymphocytes in line with the diagnosis of B-CCL. The high proportion of basophil cells (BAS) and monocytes (MON) along with the confluent population on scattergrams suggests that abnormal cells are highly prevalent. Flag “G” indicates immature granulocytes. 

The assessment of peripheral blood smear is essential. 

Blasts, immature and abnormal cells cannot be differentiated reliably with HumaCount 5L system. Due to their special response to the lyzing effect atypical and blast cells may falsely increase the basophil or monocyte counts which are shown in the result of the microscopic evaluation of the smear. 

Peripheral blood smear 

Macrocytosis is not confirmed by the microscopic analysis. Falsely elevated MCV value is caused by the extremely high WBC count which interferes with the RBC counting. The real RBC count may be somewhat lower than the displayed one. 

The Peripheral blood smear is characterized by the highly abundant lymphocytes (including atypical forms) and 

remnants of abnormally fragile lymphocytes (‘smudge cells’). The peripheral blood smear corresponds to the clinical diagnosis and indicates the progression of the disease. 

2. Other laboratory findings 

- Other laboratory findings are not remarkable. 


Chronic Lymphocytic (B-Cell) leukemia 

Disease course 

- The WBC count did not respond to the standard chemotherapeutic regime; the patient had to be switched on another one.