PMC6954171_01
Large granular lymphocytes in the peripheral blood in July 2017 (Wright-Giemsa staining, x1,000).
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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.
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).
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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).
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).
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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).
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.
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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.
Lymphoplasmacytic cells in the bone marrow comprised 5.6% of marrow nucleated cells (Wright-Giemsa staining, x1,000).
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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.