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- lymphocytes 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 Flow cytometry 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 blood 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 lymphoma 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, lymphadenopathy, bruising, or bleeding. An left the hospital before his procedure and was lost Division of Infectious evaluation for infection 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 leukemia: 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.