It’s been a while since I posted an interesting case, but here’s one that I saw in follow-up during my flow cytometry month.

The patient is a 44 yo M with a history of end-stage renal disease secondary to hypertensive nephropathy who was awaiting transplant > 2 years and undergoing peritoneal dialysis.  Fatigue and anemia and thrombocytopenia developed in late 2009 and because the anemia was attributed to his renal impairment, the thrombocytopenia was felt to be immune thrombocytopenic purpura (ITP) and he was treated with oral prednisone.  As you might expect, his fatigue persisted – as did the anemia and thrombocytopenia.  In addition, on review of systems in January he complained of drenching night sweats, fevers, a 30# weight loss and occasional nose bleeds.  Of significance he also had left upper quadrant cramping.  A physical exam at the time showed a palpable spleen and did NOT uncover any lymphadenopathy.

Labs showed the following:

WBC 6900 (normal diff), Hgb 8.6 L, MCV 101 H, Plt 37,000 L

BUN 66 H, Cr 6.35 H, Uric acid 15.9 H, LDH 1767 H (range 100-190), albumin 3.2 L, and slightly increased AST and ALT.  Calcium levels were normal.

A CT abdomen, bone marrow examination, and representative flow plots (with the population of interest painted red) showed the following.  Diagnosis?  Comments?