PMC4673078_01
Laboratory indexes; Graphical presentation of the clinical parameters during the disease course. The CRP value decreased after the 1st days of treatment with corticosteroids and antibiotics, but it never reached normal level (<8 mg/L). Body temperature curve reveals a fluctuating picture that was only briefly and temporarily stabilized at non-feverish level. Haemoglobin was normal at admission but quickly decreased below normal range (7,3-9,5 mmol/L). Leukocyte count was also normal at admission but elevated during the 1st day and the leukocytosis persisted. Thrombocytes were markedly depressed during the entire hospitalization in spite of numerous transfusions, both thrombocyte transfusions (open arrow heads) and whole blood transfusions (closed arrow heads). Green bands indicate normal values for each of the parameters
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Fig1
Despite continuous antibiotic and steroid treatment the patients' body temperature fluctuated at feverish level during most of the hospitalization period (see Fig. 1). HLA-DR and CD11b are both reported to be occasionally expressed in this disease entity, but were negative in our case (for complete flowcytometric data, see Additional file 1: Figure S1).
Morphologic features on peripheral blood smear. a (200x magnification) + b (630x magnification) May-Grunwald-Giemsa stain showing atypical cells with large, irregular folded nuclei with distinct nucleoli. The cytoplasm is basophilic with varying amount of fine granules. c CD3 immunostaining reveals a cytoplasmic reaction. d-h Representative images of the neoplasmic cells from CellaVision  showing irregular nuclei and cytoplasmic granulation
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Fig2
They revealed prominent leukocytosis with approximately 90 % of the nucleated cells showing a polymorphic cell population with variation in size and shape (see Fig. 2a). The nuclei were large with irregular foldings and variably distinct nucleoli (see Fig. 2b, d-h). The surrounding cytoplasm was lightly basophilic containing dispersed azurophilic granules (see Fig. 2a-b, d-h). Immunophenotypic evaluation showed expression of CD3 (see Fig. 2c) while TdT-staining was negative (data not shown).
Flowcytometric data of peripheral blood; Neoplastic NK-cells (green) present in CD45/SSC-plot and in SSC/FSC-plot with characteristics similar to mature monocytes (blue). Red and yellow dots show lymphocytes and granulocytes, respectively. Remaining plots show specific staining for expression of relevant peptide markers. Boxes are placed around the positive portion of cell populations in cases where positive/negative discrimination is not obvious. Only 19 % of the leukemic population was positive for HLA-DR, whereas 42, 51, 52 and 63 % of the same population was positive for CD7, cyCD3, CD16 and CD25, respectively
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Fig3
Bright expression of CD45, CD56 and CD2 lead the suspicion towards NK lineage and the concurrent dim expression of CD7, CD16 and cytoplasmic CD3epsilon consolidated the origin of the leukemia (see Fig. 3).
Molecular analysis of TCRdelta gene rearrangements in peripheral blood; Two prominent peaks are identified in fragment sizes 169 base pairs and 196 base pairs, respectively. The double-peak appearance is caused by DNA polymerase-catalyzed addition of nontemplated extra nucleotides
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Fig4
Indication of clonal rearrangements was identified in TCRD gene, where two prominent peaks were identified (see Fig. 4).