Medical Image of the Week: White Cell Count 347

Tauseef Afaq Siddiqi, MD¹

Sarah G. McGinn, MD²

Yuval Raz, MD¹

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, AZ, USA

² Department of Pathology, University of Arizona, Tucson, AZ, USA

A 77-year-old gentleman with a history of hypertension developed worsening weakness of a month duration.  His blood work at an outside facility revealed severe leukocytosis. He was transferred to University of Arizona Medical Center for leukapheresis.  His initial lab data revealed WBC count of 347.2X1000/microL (Normal 3.4-10.4X1000/microL) with 90% blasts.  His pulse oximetry was 92% on 4 L/min oxygen, although his arterial blood gas showed a pO2 of 46 (Normal 70-95 mm Hg) due to hyperleukocytosis and enhanced metabolic activity of malignant cells. His electrolyte panel showed pseudohypokalemia with potassium level of 2.4 (Normal 3.5-5.1 mMol/L).

Figure 1. Chest X-Ray showing hilar prominence and vascular fullness (interstitial and alveolar infiltrates).

Figure 2. Peripheral Blood shows increased white count with numerous blasts and promonocytes.

Figure 3. Bone Marrow Aspirate showing numerous blasts composed of a mixture of monoblasts with moderate gray blue cytoplasm and fine chromatin, and promonocytes with fine chromatin and kidney bean shaped nuclei.

Figure 4. Panel A: Bone Marrow Clot is hyerpcellular at 99% (40x magnification). Panel B: high power view of clot shows sheets of blasts (400x).

Reference as: Siddiqi TA, McGinn SG, Raz, Y. Medical image of the week: white cell count 347. Southwest J Pulm Crit Care. 2013;6(4):181-3. PDF