An unusual case of severe anaemia and lymphocytosis

An 83 year old man was referred to the haematology clinic with a three week history of fatigue and shortness of breath on exertion. His symptoms had progressively worsened and on the day of review he felt breathless at rest. He had noted that he bruised easily over his arms and had recently been admitted for recurrent chest infections that required intravenous antibiotics. He had also lost 5 kg in weight during the past month. His medical history included hypertension and elective repair of an abdominal aortic aneurysm. He had no travel history of note and did not smoke or drink alcohol. On examination he appeared pale. He had palpable lymphadenopathy in the cervical region but no palpable hepatosplenomegaly and the rest of the examination was normal. Observations were heart rate 90 beats/min, blood pressure 110/60 mm Hg, respiratory rate 18 breaths/min, oxygen saturations 98% on room air, and temperature 37°C. Blood test showed haemoglobin 44g/L (reference range 133-167), white blood cell count 125×109 cells/L (3.5-11), lymphocytes 122.4×109 cells/L (1.0-3.0), neutrophils 0.39×109 cells/L (2.0-7.0), platelets 54×109/L (150-410), reticulocytes 1×109/L (25-75), and C reactive protein 114.2 nmol/L (0.76-28.5). Urea, creatinine, and liver function tests including bilirubin were normal. Parvovirus polymerase chain reaction was positive at 172 000 copies and cytomegalovirus, adenovirus, and Epstein-Barr virus polymerase chain reaction were negative. A direct antiglobulin test was negative. Figure 1⇓ shows his bone marrow aspirate and fig 2⇓ shows his peripheral blood film. On flow cytometry, 55% of the bone marrow leucocytes were clonal, κ light chain restricted, and positive for CD5, CD19, CD38, and CD43; weakly positive for CD20; and negative for CD22 and CD79b.