Another on-line case study: “A 54 year old man presents to the hospital with a two week history of a sore throat and flu like symptoms. He has previously been entirely well. His General Practitioner has treated him with antibiotics but this has not led to any improvement in his symptoms. On examination he appears quite well but he does have enlarged lymph glands in the neck. A number of blood tests are performed including a blood count and blood film. His biochemical screen shows mild renal failure and a very elevated lactate dehydrogenase level”
My gut feeling was that this was adult acute lymphoblastic leukaemia, or (bearing in mind the lymph node involvement) a lymphoma of some sort.
On submitting my answer I was told that although I’d got all the cell identification and morphology stuff right, the expert opinion was that this is a case of Burkitt’s lymphoma.
However the expert opinion did go on to say that “no definitive diagnosis will be possible from the blood film morphology alone”. It then mentioned “…rapidly proceed with more discriminatory investigations. This must include bone marrow aspiration and trephine biopsy with performance of immunophenotyping and cytogenetics”; none of which were available for the purposes of this exercise.
I must admit I’m getting a tad fed up with these exercises: if a diagnosis is going to depend on a certain test then that test result should be available. Presenting me with horse dung and hoof prints and then saying “zebra!!” is a bit unfair…..
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ReplyDeleteI would suggest a PAS stain and Ki-67 to definitely identify it as a Burkitt type lymphoma, a small percentage of which can have a leukemic phase
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