case_images: PMC11786526_01
case_images: Peripheral blood smear from a patient with B-cell prolymphocytic leukemia (B-PLL).. The image was acquired using a 10x ocular and a 100x oil-immersion objective lens, following Wright-Giemsa staining. Several large prolymphocytes with prominent nucleoli and scant basophilic cytoplasm are visible, exhibiting a high nuclear-to-cytoplasmic ratio. Red blood cells (RBCs) appear reduced in density, consistent with the patient's anemia, and are distributed throughout the field.
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case_images: PMC11786526_01_cureus-0017-00000076787-i01.jpg
case_images: FIG1
case_images: Occasional smudge cells were also noted but did not comprise a significant proportion of the smear (Figure 1).
case_images: Bone marrow smear of a patient with B-cell prolymphocytic leukemia (B-PLL).. The bone marrow smear from a patient with B-cell prolymphocytic leukemia (B-PLL) reveals significant infiltration with large prolymphocytes as the predominant cell type. These cells are characterized by large nuclei with a high nuclear-to-cytoplasmic ratio, moderately condensed chromatin, and prominent, centrally located nucleoli. The cytoplasm is pale basophilic, moderate in amount, and lacks visible granules. The background shows a sparse presence of erythroid and myeloid precursors, indicative of extensive bone marrow involvement by the leukemic process, with occasional platelet fragments visible. The smear was stained using the Wright-Giemsa staining technique, which highlights nuclear morphology and cytoplasmic features with excellent contrast. The image was observed under a microscope using a 10x ocular lens and a 100x oil immersion objective lens, providing a total magnification of 1000x. These findings are consistent with the diagnosis of B-PLL, a rare and aggressive B-cell malignancy.
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case_images: PMC11786526_01_cureus-0017-00000076787-i02.jpg
case_images: FIG2
case_images: Morphologic assessment identified a preponderance of relatively immature lymphoid cells characterized by basophilic, plasmacytoid cytoplasm and a small nuclear vacuole, consistent with prolymphocytes (Figure 2).
case_images: Marker expression profile in bone marrow flow cytometry.. This horizontal bar chart illustrates the expression percentages of various immunophenotypic markers identified in bone marrow flow cytometric analysis. The analysis confirmed a clonal population of B cells characterized by high expression of CD19, CD20, CD22, and CD38, along with bright surface immunoglobulin (IgM, 97%) and lambda light chain restriction (100%). Notably, markers typically associated with other B-cell neoplasms, including CD23, CD5, CD10, CD25, CD33, and CD34, were absent (0%). Similarly, markers indicative of myeloid or hairy cell differentiation, such as CD103, CD11c, CD123, and Cyclin D1, were also absent. The results support the diagnosis of a distinct B-cell lymphoid malignancy while effectively excluding other neoplastic conditions, including mantle cell lymphoma, chronic lymphocytic leukemia, and hairy cell leukemia.
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case_images: PMC11786526_01_cureus-0017-00000076787-i03.jpg
case_images: FIG3
case_images: In addition, the leukemic variant of mantle cell lymphoma (MCL) - commonly associated with the t(11;14)(q13;q32) translocation - was excluded by fluorescence in situ hybridization (FISH) analysis, which showed no evidence of this abnormality (Figure 3).
case_images: White blood cell (WBC) count trends over 110 weeks following treatment.. This line chart demonstrates the trends in WBC count over a period of 110 weeks. The initial WBC count was markedly elevated at 213.82 x 109/L, and a gradual reduction was observed, with fluctuations, until the final recorded count of 8.62 x 109/L. The dashed red line represents the upper normal limit of the WBC count (11 x 109/L), while the dashed green line indicates the lower normal limit (4 x 109/L). These data reflect a positive response to the administered treatment, as the patient's WBC count decreased progressively and approached normal levels over time. The fluctuations in WBC counts are consistent with treatment adjustments and disease dynamics but do not deviate from the overall downward trend.
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case_images: PMC11786526_01_cureus-0017-00000076787-i04.jpg
case_images: FIG4
case_images: The trajectory of the patient's WBC count over time, reflecting a positive response to therapy, is illustrated in Figure 4. Statistical analysis of the CBC trends revealed a significant reduction in the patient's WBC count from an initial 213.82 x 109/L to 8.62 x 109/L posttreatment, illustrating a robust hematologic response to the R-B regimen (Figure 4).