CLINICAL IMAGES

“Soccer-Ball” Lymphocytosis

Jena L. Utz, BS, MT; Heidi Bell, MT (ASCP); William F. Wright, DO, MPH; Tracy I. George, MD

1 From the University of n 87-year-old man with a history of par- and smudge cells. Some refer to Pittsburgh Medical Health oxysmal atrial fibrillation, hypertension, these cells as “soccer-ball” lymphocytes because System in Pennsylvania. A and chronic kidney disease presented to the nucleus is very mature, dark, and can have a Disclaimer: Dr Wright, a JAOA the emergency department with confusion, weak- “cracked” appearance.2 analysis associate editor, was not ness, and shortness of breath with nonproductive detected κ monotypic B-cells with a non-CLL involved in the editorial review or decision to publish this cough. Laboratory studies revealed a white immunophenotype clone (positive CD19, dim 9 article. cell count of 41,300 × 10 /L, an absolute lympho- CD20, negative CD5 and CD23 expression). 9 Financial Disclosures: cyte count of 23,500 × 10 /L, a hemoglobin level Monoclonal B lymphocytosis, a precursor form of 9 None reported. of 9.8 g/dL, a platelet count of 280,000 × 10 /L, CLL, was diagnosed. Marginal zone and lympho-

Support: None reported. and a creatinine level of 1.16 mg/dL. On physical plasmacytic were also considered. examination, the patient had no hepatosplenome- Bone marrow biopsy was planned, but the patient Address correspondence to William F. Wright, DO, MPH, galy, , bruising, or bleeding. An left the hospital before his procedure and was lost Division of Infectious evaluation for or autoimmune conditions to follow-up. (doi:10.7556/jaoa.2020.046) Diseases, Department of was unrevealing. A peripheral blood smear Medicine, Johns Hopkins revealed smudge cells (image A) and small round University School of Medicine, References 733 N Broadway, Baltimore, lymphocytes with coarsely clumped chromatin 1. Inamdar KV, Bueso-Ramos CE. Pathology of chronic lymphocytic MD, 21205. (image B) characteristic of chronic lymphocytic : an update. Ann Diagn Pathol. 2007;11(5):363-389. doi:j.annadiagpath.2007.08.002 Email: [email protected] leukemia (CLL; Wright-Giemsa stain). 2. Zhao XF. Pitfalls in diagnostic hematopathology: part I. Int J Clin Chronic lymphocytic leukemia typically pre- Exp Pathol. 2009;2(1):11-20.

Submitted sents with an increased number of small mature © 2020 American Osteopathic Association July 31, 2019; accepted September 19, 2019.

286 The Journal of the American Osteopathic Association April 2020 | Vol 120 | No. 4