Bruised

A 49 year old woman presents with upper abdominal pain, intermittent nausea and vomiting, malaise, and night sweats for 3 weeks, in association with a 6 kg weight loss.

She also experienced easy bruising during the same period. There was no history of epistaxis, hematemesis, melena, or other bleeding manifestations.

Her medical, surgical, and drug histories are unremarkable. There is no family history of bleeding disorders.

She does not smoke, drink or use recreational drugs. Her ESR is 31 mm/1h.

Select Relevant Investigations
Complete Blood Count + Peripheral Smear

Performed

WBC/DC: 12,900 /mm3 (4,500-10,500)
Lymphocytes: 9,900 /mm3
Hb: 10.3 g/dL (10.5-18)
Hct: 37% (36-44)
RBC: 4.1x10^6/ml (4.0-4.9)
Platelets: 82x10^3/mL (150-450x10^3)

The peripheral smear shows rouleaux formation, with atypical lymphocytes and plasmacytoid cells.
Liver Profile

Performed

Total Bilirubin: 1.1 mg/dL (0.1-1.2)
AST: 38 U/L (<35)
ALT: 37U/L (<35)
ALP: 142 U/L (33-131)
GGT: 78 U/L (0-51)
Total Protein: 9.3 g/dL (6.0-8.3)
Albumin: 2.9 g/dL (3.2-5.0)
INR: 1.2 (0.8-1.1)
LDH: 315 U/L (56-194)
Bone Marrow Aspiration + Biopsy

Performed

The bone marrow aspirate reveals a population of small, atypical lymphocytes admixed with normal cells.

H&E staining of the trephine biopsy specimen demonstrates large intratrabecular lymphoid aggregates; immunostaining reveals the lymphiod cells to be CD20 positive and CD10 negative.

Flow cytometry shows 77% of the lymphoid cells to be CD19, CD20, CD79b and cytoplasmic kappa positive, and negative for CD5, CD10, CD38 and CD138.
Serum Protein Electrophoresis

Performed

Serum electrophoresis reveals a large IgM component (>30 g/L), along with a a mild increase in serum IgG concentrations. Immunofixation reveals a monoclonal band which fixes anti-IgM and anti-kappa.

Bence-Jones proteins are not detected.

Select Relevant Management
Plasmapheresis
Rituximab
Cyclophosphamide
Allogenic Stem Cell Transplantation