A six year old male with worsening lymphadenopathy on amoxicillin

This 6 year old white male presenting with a bump on his neck that was initially
thought to represent an infection and a course of amoxicillin was started. Despite

Peripheral Blood
WBC

15.2 10x9/L

RBC

4.45 10x12/L

Hgb

12.5 g/dL

Hct

36.6 %

MCV

82.3 fL

MCH

28.1 fL

MCHC

34.1 g/dL

RDW

11.9 %

PLT

254 10x9/L

Retic
Retic
antibiotic therapy the bump increased in size over the past week. A peripheral blood
smear at the referring hospital was interpreted as having a question of increased
blasts. Bone marrow to rule out leukemia.

Peripheral Blood Differential

Cell Type

Percentage

Abs. No.

Polys

11 %

1.67

Lymphs

38 %

5.78

Atyp. Lymphs

45 %

6.84

Monos

5%

0.76

Eos

1%

0.15

Bands

Baso
Blasts
Promyelos
Myelos
Metamyelos
NRBC/100 WBC

The peripheral blood smear was reviewed.

RED BLOOD CELL MORPHOLOGY:
Slight anisocytosis, slight poikilocytosis, polychromasia.
WHITE BLOOD CELL MORPHOLOGY:
Abundant atypical lymphocytes , some of which contain granules.
atypical lymphocyte :

some of which contain granules

PLATELETS are adequate with occasional large forms seen.

BONE MARROW:The marrow aspirate smear is adequate for interpretation with cellular
spicules seen. Four aspirate smears and zero touch imprints reviewed.
Bone Marrow Differential
Blasts

2.3 %

Promyelos

1.5 %

Myelos

10.2 %

Metamyelos

6.4 %

Bands

9%

PMN

10.2 %

Eos Myelo/Metas

0.8 %

Eos Bands
Eos Segs

1.5 %

Basos

0.4 %

Monos

5.3 %

Pronormos

3.8 %

Normos

24.4 %

Lymphos

24.1 %

Plasma Cells

0.4 %

Others
Myeloid:Erythroid Ratio 1.7
Total # of cells counted: 300

Atypical lymphocytes were seen upon scanning. Histiocytes with cytoplasmic debris as well as
many naked nuclei are noted.
Atypical lymphocytes :

naked nuclei

ERYTHROID MATURATION is complete and slightly megaloblastoid.

MYELOID MATURATION is complete and slightly megaloblastoid with asychrony of

maturation and retention of primary granules.
MEGAKARYOCYTES are present. Megakaryocytes include occasional hypersegmented
forms.

Results: Cell suspension immunophenotypic studies were performed on the bone marrow
aspirate and one region was analyzed.
Region 1 represents the small non-complex cells (52% of the events).

VIABILITY: 99%
B Cells
Antigen

Usual Specificity

% Positive

Kappa +

B Cell Subset

Lambda +

B Cell Subset

Kappa:Lambda Ratio

0.7

CD19+

B Cell

11

CD19+/CD5+

B Cell Subset

CD20+

B Cell

CD10+ (Calla)

B Cell Subset

T Cells
Antigen

Usual Specificity

% Positive

CD2+

T Cell

84

CD3+ Total

T Cell

78

CD5+/CD19-

T Cell

74

CD7+

T Cell

72

CD4+/CD8-

T Helper

13

CD8+/CD4-

C Cytotoxic/Suppressor

63

CD4+/CD8+

T Cell Subset

CD4:CD8 Ratio

T Helper:Suppressor Ratio

0.2

CD16,CD56+/CD3+

T Cell Subset

CD16,CD56+/CD3-

NK Cells

Myeloid
Antigen

Usual Specificity

% Positive

CD15+

Myeloid

CD34+

Stem Cell

Additional Antibodies
Antigen

Usual Specificity

% Positive

CD45+

Leukocytes

96

HLA DR+

B, Myeloid, Activated T

78

TdT+

Lymphoblasts (Myeloblasts)

Cyto CD3+

T Cells

76

CD22+

Interpretation:
Flow cytometric immunophenotypic studies reveal an increased population of CD3+ Tlymphocytes (78%). This poulation also showed a low CD4:CD8 ratio (0.2) and strong
expression of HLA-DR antigen (78%). These findings are consistent with infectious
mononucleosis.
FINAL DIAGNOSIS:
Part 1: PERIPHERAL BLOOD MILD LEUKOCYTOSIS (lymphocytosis). (see comment)
Part 2: BONE MARROW ASPIRATE TRILINEAGE MATURATION AND MILD LYMPHOCYTOSIS.
Comment:
The morphological findings are commonly associated with EBV infection (45% atypical
lymphocytes).
Contributer's Note:
This case was chosen because of the classic hematologic findings and the opportuniy to perform
flow cytometric studies on this bone marrow aspirate. (Flow cytometry was performed at no
charge to the patient and used for educational purposes only.) Although the Epstein Barr virus
infects the B-lymphocytes, it results in an expansion of the CD8+ T-lymphocyte population in the
peripheral blood. This population of cells also demonstrates increased expression of HLA-DR
antigen which is consistent with in vivo activation(Clin exp Immunol 1991;83:447-451). These
findings were confirmed in the bone marrow aspirate in this case. We were unable to review the
peripheral blood slide from the outside hospital to confirm the presence of blast-like cells.