#00065128

A 65-year male presented with easy fatigability and pallor since one month. On examination mild splenomegaly of 3 cms below left costal margins with axillary lymphadenopathy was noted. Complete blood counts showed severe anemia (50 g/L) with 0.3% corrected reticulocyte count, normal WBC and moderate thrombocytopenia (62 x 10⁹/L). Direct Coomb’s test for monospecific IgG and C3d were negative. Peripheral smear showed moderate anisopoikilocytosis without rouleaux formation. Serum protein electrophoresis did not show any monoclonal band; serum total proteins (6.86 g/dL) and albumin (4.45 g/dL) values were normal. Renal function tests, liver function tests and serum calcium values were normal except for mild unconjugated hyperbilirubinemia (total bilirubin was 2.1 mg/dL and conjugated bilirubin was 0.5 mg/dL). Urine examination was normal with no monoclonal band or urinary proteins. Bone marrow aspirate showed numerous varying sized plasma cells including large flame cells packed with immunoglobulins. Many binucleate plasma cells and large cytoplasmic eosinophilic globules were noted (Image A, B). Flow cytometry for gated plasma cells showed positivity for CD43, CD20, CD200 and kappa restriction. Trephine biopsy showed sheets of vacuolated plasma cells giving a pseudo appearance of histiocytic collections (Image C). These plasma cells showed cytoplasmic positivity with CD138 (Image D). The patient has not opted for therapy.