A CBC shows Hgb 104 g/L, WBC 68 x 10^9/L with lymphocytosis and smear showing smudge cells. Bone marrow is dry tap with fibrosis and DAT is positive. What is the presumptive diagnosis?

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Multiple Choice

A CBC shows Hgb 104 g/L, WBC 68 x 10^9/L with lymphocytosis and smear showing smudge cells. Bone marrow is dry tap with fibrosis and DAT is positive. What is the presumptive diagnosis?

The key idea is a mature B-cell lymphoproliferative disorder presenting with persistent lymphocytosis in an older patient, with a peripheral smear that shows fragile lymphocytes forming smudge cells. Those smudge cells are a classic hint toward chronic lymphocytic leukemia. The very high white count driven by lymphocytes and the positive direct antiglobulin test fit with CLL, since autoimmune phenomena like autoimmune hemolytic anemia commonly accompany it. While a dry tap with marrow fibrosis might suggest hairy cell leukemia, that disorder typically presents with monocytopenia and distinctive hairy cells on smear, not a prominent lymphocytosis with smudge cells. Thus, the overall pattern most consistent with chronic lymphocytic leukemia. Confirmation would come from immunophenotyping showing B cells with markers such as CD5 and CD23.

The key idea is a mature B-cell lymphoproliferative disorder presenting with persistent lymphocytosis in an older patient, with a peripheral smear that shows fragile lymphocytes forming smudge cells. Those smudge cells are a classic hint toward chronic lymphocytic leukemia. The very high white count driven by lymphocytes and the positive direct antiglobulin test fit with CLL, since autoimmune phenomena like autoimmune hemolytic anemia commonly accompany it. While a dry tap with marrow fibrosis might suggest hairy cell leukemia, that disorder typically presents with monocytopenia and distinctive hairy cells on smear, not a prominent lymphocytosis with smudge cells. Thus, the overall pattern most consistent with chronic lymphocytic leukemia. Confirmation would come from immunophenotyping showing B cells with markers such as CD5 and CD23.

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