A 6-year-old girl presented to her pediatrician with symptoms of fatigue, pallor, bruising, and a pronounced limp. Physical examination revealed moderate splenomegaly, mild lymphadenopathy, and a fever of 101°F CBC results were as follows:
WBC 60.6 X 109/L LDH
RBC 2.90 X 1012/L Reticulocytes
Hgb 7.9 g/dL PT/aPTT
MCV 82 fL
MCH 27.2 pg
MCHC 32.8 g/dL
Platelets 23 X 109/L
Differential: 2 band neutrophils
4 segmented neutrophils 10 lymphocytes 1 monocyte 83 balsts
Considering the patient's age and the fact that she has 83% blasts in her peripheral smear, a diagnosis of acute leukemia is highly likely. There is also evidence of hemolysis since the LDH is extremely elevated. The reticulocyte count is low and not representative of a regenerative bone marrow. This is probably due to the crowding out of the normal elements of the bone marrow. A bone marrow biopsy was ordered and showed sheets of small blasts with scanty cytoplasm and indistinct nucleoli. The cytochemical stains were SBB negative and NSE negative. The PAS was positive. Immunopheno-typing results showed TdT positive and cells positive for CD10, CD19, CD20, CD24, and CD34. These findings suggest a pre-B acute lymphoblastic leukemia.
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