Teaching Cases from the Royal Marsden Hospital Case 9: An elderly patient with unusual circulating cells

Abstract

CASE An 80-year-old woman was referred for investigation of recent onset bruising. She had no specific symptoms but felt generally unwell. Past medical history included appendicectomy and lobular carcinoma of the: right breast which had been treated initially with tamoxifen and subsequently by local excision and radiotherapy. She had a single 1 cm lymph node in the right axilla and 6 cm hepatomegaly. The spleen was not palpable. There were scattered small bruises but no petechiae. A blood count showed: WBC 20 × 10⁹, Hb 10.7 g/dl, platelet count 88 × 10⁹/l and reticulocyte count 88 × 10⁹/l. The blood film was leucoerythroblastic and red cell fragments were present. Fibrin degradation products (D dimer) were between 0.25 and 0.5 mg/l (NR < 0.25) but a coagulation screen was otherwise normal. Bone marrow infiltration and microangiopathic haemolytic anaemia were suspected. There was a rapid clinical deterioration and one week later laboratory tests showed: WBC 34 × 10⁹/l, Hb 10.8 g/dl, platelet count 114 × 10⁹/l, bilirubin 42 mol/l (NR < 17), alkaline phosphatase 306 U/l (NR 30–130), alanine transferase 132 U/l (NR < 40), albumen 33 g/l (NR 35-51) and calcium 2.18 mmol/l (NR 2.15-2.55). The blood film was leucoerythroblastic with red cell fragments, Howell-Jolly bodies and abnormal cells (Fig. 1) which were 20% of circulating nucleated cells and showed a tendency to cluster. A diagnostic procedure was performed.

Key Words:

• carcinoma
• carcinocythaemia
• leukaemia