• Users Online: 891
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 58-59

An Unusual Presentation of Atypical Lymphocytosis


1 Senior Resident, Dept of Biochemistry, IGIMS, Patna, India
2 Assistant Professor, Dept of Pediatrics NMCH, Patna, India
3 Haemato - oncologist, Paras HMRI Hospital, Patna, India
4 Professor, Dept of Biochemistry, IGIMS, Patna, India
5 Additional Professor, Department of Biochemistry, IGIMS, Patna, India
6 Associate Professor, Department of Biochemistry, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Priyanka Prasad
Senior Resident, Dept. of Biochemistry, IGIMS, Patna, Bihar
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
  Abstract 


A 2 years old boy presented with cold, cough, fever (respiratory distress) for 5 days and irritability for 3 days. On examination he had marked Pallor with hepatosplenomegaly. He was referred to the haematology depart-ment for work up. Complete Blood Count with Peripheral Blood film examination suggestive of Acute Lym-phoblastic Leukaemia. Atypical immature blasts are seen in peripheral blood. They have irregular nuclear outline with convolutions. RBCs show dismorphic cell population. Bone marrow aspiration showed presence of blast cells, fine nuclear chromatin with presence of nucleoli. Chest X ray revealed Hilar prominence. Morphologic findings are those of acute leukemia, possibly Acute lymphoblastic leukaemia (ALL) but Flow cytometry sug-gestive of 16% immature myelomonocytic precursor cells with monocytic differentiation. On follow up after 3 months no. of blasts cells and monocytic cells has come down significantly suggesting reactive cause of previ-ous proliferation exclude noninfectious causes(usually a hematologic malignancy).

Keywords: Acute lymphoblastic leukaemia, Peripheral blood, Blasts


How to cite this article:
Prasad P, Kumar R, Singh AK, Kumar U, Kumari R, Shekhar R. An Unusual Presentation of Atypical Lymphocytosis. J Indira Gandhi Inst Med Sci 2018;4:58-9

How to cite this URL:
Prasad P, Kumar R, Singh AK, Kumar U, Kumari R, Shekhar R. An Unusual Presentation of Atypical Lymphocytosis. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:58-9. Available from: http://www.jigims.co.in/text.asp?2018/4/2/58/302960




  Introduction: Top


The causes of lymphocytosis range from the be-nign self- limiting response seen in certain infections to frank malignancy[1]. It is usually possible to differentiate benign from malignant lymphocytosis on the basis of the clinical picture, the blood film, and a small number of widely available investigations[2],[3]. Atypical lymphocytosis due to infections is classically seen in viral and chronic bacterial infections[4],[5]. The investigation of lymphocytosis is largely determined by the morphological appearance of the cells. Atypical lymphocytosis is definite when 20 per cent or more of the mononuclear cells are atypical lymphocytes[6],[7],[8]. The increased number of atypical lymphocytes in many nonviral as well as viral illnesses is viewed as a nonspecific cellular response to a stimulus that is probably antigenic.

Atypical lymphocytes have been observed in the peripheral blood of patients in a large number of clinical situations, including immune reactions to transplantation and immunization, collagen diseases and other autoimmune disorders, malignant disease, drug reactions, and infectious mononucleosis, as well as other bacterial and viral infections[9],[10],[11].


  Case Report: Top


A 2 years old boy presented to clinic with cold, cough, fever (respiratory distress) for 5 days and irritability for 3 days. On physical examination he had marked Pallor with hepatosplenomegaly. He was referred to the haematology department for work up as follows :

  • CBC with Peripheral Blood film examination suggestive of Acute Lymphoblastic Leukaemia. Atypical immature blasts are seen in peripheral blood. They have irregular nuclear outline with convolutions. RBCs show dismorphic cell population. CBC showed low Hb = 6g/dl, increased total WBC count = 19..2 ×109/L and platelet count = 183 × 109/L which was normal. A differential count revealed 4% neutrophils, 52% lymphocytes and 38% atypical lymphocytes.
  • Bone marrow aspiration showed presence of increased number of blast cells. These blasts have moderate amount of basophilic cytoplasm, fine nuclear chromatin with presence of nucleoli.
  • Blood culture did not reveal any growth.
  • Chest X ray revealed Hilar prominence.


Morphologic findings are those of acute leukemia, possibly Acute lymphoblastic leukaemia (ALL) but Flow cytometry suggestive of 16% immature myelomonocytic precursor cells, (Juvenile Myelomonocytic Leukemia (JMML)?? Acute myeloid leukemia (AML) with monocytic differentiation?).

On follow up after 3 months no. of blasts cells and monocytic cells has come down significantly suggesting reactive cause of previous proliferation exclude noninfectious causes (usually a hematologic malignancy).


  Discussion: Top


The case presented with cold, cough, fever and irritability. He had hepatosplenomegaly but no lymphadenopathy. Clinical features suggested acute infective pathology. CBC revealed marked anemia and leukocytosis. Atypical immature blasts are seen in peripheral blood. A diagnosis of atypical lymphocytosis was made. Elevation of the lymphocyte count is most commonly due to a reactive lymphocytosis, the body's normal response to an acute infection or inflammatory condition. With patients in whom a reactive lymphocytosis is suspected, a thorough infectious workup should be performed. The mechanisms leading to an increased number of circulating lymphocytes include increased lymphocyte production, release of already formed lymphocytes into the blood, or decreased clearance of lymphocytes from the blood. A less common etiology of an elevated lymphocyte count is malignant lymphocytosis, where the lymphocyte count becomes elevated due to either an acute or chronic lympho- proliferative disorder.

An elevated lymphocyte count alone is unlikely to cause harm. Therefore, taking time to identify the underlying cause is essential, as treatment will differ substantially between reactive and malignant causes.


  Conclusion: Top


The identification of monoclonality is not an absolute indication for treatment and the decision whether to undertake this in an individual patient must be based on the clinical picture as well as the nature of the lymphocyte involved.



 
  References Top

1.
Mims CA, Playfair JHL, Roitt IM, Wakelin D, Williams R, Anderson RM. Medical Microbiology Part 1.2London: Mosby; 1993.  Back to cited text no. 1
    
2.
Hoffbrand AV, Catovsky D, Tuddenham EGD. Postgraduate Hematology. 5th ed. Oxford: Blackwell; 2005.  Back to cited text no. 2
    
3.
Behrman RE, Vaughan VC. Nelson Test book of Pediatrics. 12th ed. Philadelphia: WB Saunders Company; 1983.  Back to cited text no. 3
    
4.
Hoffbrand AV, Pettit JE, Moss PAH. Essential Hematology. 4th ed. Oxford: Blackwell; 2001.  Back to cited text no. 4
    
5.
Lee GR, Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers GM. Wintrobe's Clinical Hematology, 10th ed. Philadelphia: Lippincott, Williams & Wilkins, 1999.  Back to cited text no. 5
    
6.
Deyi YM, Goubau P, Bodeus M. False positive IgM antibody tests for Cytomgalovirus in patients with acute Epstein Barr virus infections. Eur J Clin Microbiol Infect Dis, 2000; 19:557-560.  Back to cited text no. 6
    
7.
Behrman RE, Vaughan VC. Nelson Test book of Pediatrics, 12th ed. Philadelphia: WB Saunders Company  Back to cited text no. 7
    
8.
Hunger SP, Mullighan CG. Acute Lymphoblastic Leukemia in Children. N Engl J Med 2015; 373:1541.  Back to cited text no. 8
    
9.
Svendsen AL, Feychting M, Klaeboe L, et al. Time trends in the incidence of acute lymphoblastic leukemia among children: a population-based Nordic study. J Pediatr 2007; 151:548. 1976-2002.  Back to cited text no. 9
    
10.
Turner A. Wood, Eugene P. Frenkel. The American Journal of Medicine, Vol: 42, Issue: 6, 1967 Page: 923-936.  Back to cited text no. 10
    
11.
Thomas A. Shiftan, John Mendelsohn. Human Pathol-ogy, Vol: 9, Issue: 1, 1978. Page: 51-61.  Back to cited text no. 11
    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction:
Case Report:
Discussion:
Conclusion:
References

 Article Access Statistics
    Viewed458    
    Printed12    
    Emailed0    
    PDF Downloaded24    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]