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A 53-year-old male presents with confusion. progressive weakness. and weight loss. Physical examination reveals bilateral inguinal lymphadenopathy and splenomegaly. Laboratory workup is significant for a leukocyte count of 9LJ.OOO/,LLL. hemoglobin of 7.LJ g/dl. and platelet count of 27.000/,LLL. Creatinine is elevated at 5.7 mg/dl. with no prior history of renal impairment. LDH and uric acid levels are found to be elevated at 1.850 U/L and 13.8 mg/dl. respectively. CT scan of the abdomen reveals massive lymphadenopathy. Flow cytometry of the peripheral blood shows expression of CD19. CD20. and HLA-DR on the surface of the abnormal leukocytes. Peripheral blood smear is shown below.
What is the most likely diagnosis?
- Chronic lymphocytic leukemia (CLL)
- Intravascular large cell lymphoma (ILCL)
- Diffuse large B-celllymphoma (DLBCL)
- Adult T-cellleukemia/lymphoma (ATLL)
- Sezary syndrome (SS)
Medicine
C. Peripheral slide reveals evidence of circulating large leukocytes exhibiting prominent nucleoli and typical B-cell markers. Imaging studies revealed massive lymph node conglomerate in the abdomen. DLBCL presenting in leukemic phase is the most appropriate of the choices given. Lymph node biopsy confirmed the diagnosis of DLBCL. Lack of expression ofT-cell markers excludes the diagnosis of ATLL and SS, both of which are T-cell malignancies. CLL is excluded by the lack of typical morphology and negative expression of CDS and CD23. ILCL is a rare subtype oflarge cell lymphoma, most commonly of B-celllineage, that is characterized by the proliferation of lymphoma cell within small blood vessels with absence of circulating lymphoma cells and lack of extravascular tumor masses (Br l Haematol. 2012;158(5):608, l Clin Oneal. 2007;25(21):3168, Blood. 2007;109(2):478, Br J Haematol. 2004;127(2): 173 ).
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