case_images: PMC6954171_01
case_images: Large granular lymphocytes in the peripheral blood in July 2017 (Wright-Giemsa staining, x1,000).
case_images: jslrt-59-202-g001.jpg
case_images: PMC6954171_01_jslrt-59-202-g001.jpg
case_images: f1
case_images: Laboratory examination demonstrated a WBC count of 2.7x109/L, with 12.9% neutrophils, 0.9% eosinophils, 1.3% basophils, 20.4% monocytes, 29.8% lymphocytes, and 34.7% LGL (Figure 1), a hemoglobin concentration of 11.3 g/dL, and a platelet count of 5.0x109/L.
case_images: Flow cytometric analysis of peripheral blood performed using strong CD45 gating. The value in each area in respective cytograms indicates % of cells among CD45-strongly positive mononuclear cells. Based on these data, the % of CD3+/CD4+/CD8dim/CD57+ and CD3+/CD4-/CD8+/CD57+ populations in WBC (nucleated cells) were 16.0% and 20.9%, respectively (Figure 2A). These CD4+ and CD8+ cell populations also expressed granzyme B and perforin (Figure 2B).
case_images: jslrt-59-202-g002.jpg
case_images: PMC6954171_01_jslrt-59-202-g002.jpg
case_images: f2
case_images: Flow cytometry (FCM) of peripheral blood demonstrated 16% CD3+/CD4+/CD8dim/CD57+ and 20.9% CD3+/CD4-/CD8+/CD57+ populations in nucleated cells with a CD4/CD8 ratio of 0.86 (Figure 2A).
case_images: An M-peak was observed on serum electrophoresis (arrow) (Figure 3A), and immunofixation showed monoclonal bands of IgG-lambda and faint IgA with an unknown light chain (arrows) (Figure 3B).
case_images: jslrt-59-202-g003.jpg
case_images: PMC6954171_01_jslrt-59-202-g003.jpg
case_images: f3
case_images: An M-peak was observed on serum electrophoresis (Figure 3A), and immunofixation revealed monoclonal bands of IgG-lambda and faint IgA with an unknown light chain (Figure 3B).
case_images: Flow cytometric analysis of bone marrow cells with strong CD45 gating. The value in each area in respective cytograms indicates the % of cells among CD45-strongly positive mononuclear cells. The analysis subsequently revealed a population with a CD19+/smlambda+/smkappa- phenotype comprising 3.8% of marrow nucleated cells. Cytoplasmic immunoglobulin analysis showed that cyalpha+/cylambda+, cylambda+, and cykappa- cells comprised 1.2, 5.9, and 0.3% of marrow nucleated cells, respectively. Surface and cytoplasmic IgG were not detected, possibly due to unknown problems associated with the use of monoclonal anti-IgG antibody in this analysis.
case_images: jslrt-59-202-g004.jpg
case_images: PMC6954171_01_jslrt-59-202-g004.jpg
case_images: f4
case_images: On FCM analysis of bone marrow cells, a B-cell population with a CD19+/CD38+/smlambda+/smkappa- phenotype comprised 3.8% of marrow nucleated cells (Figure 4). CD19+ cells, cyalpha+/cylambda+, cylambda+, and cykappa- cells comprised 1.2, 5.9, and 0.3% of marrow cells, respectively (Figure 4). Considering the results of serum immunofixation and marrow FCM analyses, there were 2 clonal B-cells producing IgG-lambda and IgA-lambda in the bone marrow.
case_images: Lymphoplasmacytic cells in the bone marrow comprised 5.6% of marrow nucleated cells (Wright-Giemsa staining, x1,000).
case_images: jslrt-59-202-g005.jpg
case_images: PMC6954171_01_jslrt-59-202-g005.jpg
case_images: f5
case_images: The bone marrow picture was non-specific except for LGL and lymphoplasmacytic cells (Figure 5), which comprised 5.0 and 5.6% of nucleated cells, respectively.