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79years of male referred to the emergency department with complaints of bi-cytopenia with an history of bleeding episode.On initial workup with routine investigations complete blood count showed Hb-7.6g/dl,Total WBC count-15,640 and platelets-19thousand. Routine biochemical investigations showed elevated LDH-1724 international units/L and uric acid 14.0mg/dl. Peripheral smear showed features of 60% atypical cells (Figure-1) resembling blasts with prominent nucleoli. Few of the atypical cells showed nuclear cleaving , and a diagnosis of leukemia/ lymphoma spill over was given in view of age and morphology.
Bone marrow studies were performed in view of leukemia along with Flowcytometry.
Bone marrow aspirate was aparticulate and hemodiluted. Imprint smears was cellular with presence of atypical cells with few showing basophilic cytoplasm and vacuolations. (Figure 2).A diagnosis of possible leukemia and lymphoma spill over was given. Flowcytometry findings done elsewhere showed blasts positive for HLADR ,CD38, CD19,CD10 ,cytoplasmic CD79A and Negative for CD20,CD34 and other myeloid and T cell immunophenotypic markers. Hence a diagnosis of a possible diagnosis of B precursor Acute lymphoblastic leukemia was given however rare case of CD20 negative diffuse large B cell lymphoma was note excluded in view of PET CT findings showing significant intra abdominal lymphadenopathy and morphology. Advised correlation with karyotyping studies. Bone marrow biopsy showed complete replacement of marrow spaces by sheets of large lymphoid cells with prominent nucleoli with many mitotic figures consistent with infiltration by high Non Hodgkin ‘s lymphoma (Figure-3).Karyotyping Analysis revealed complex karyotype with t(14;18)(q32;q21), add(13q), -8, -17 (Figure-4)suggestive of follicular cell origin with a possible transformation of follicular into large B cell lymphoma with a leukemic spill over.