Question

Here is your assigned case problem: A 34-year-old woman came to the physician with a 2-month history of increasing weakness, persistent nonproductive cough, fever and chills accompanied by night sweats, and a 13-pound weight loss over a 6-month period. Results of chest radiographs and purified protein derivative test (for tuberculosis) were negative. The patient was treated with ciprofloxacin and her cough improved, but she continued to grow weaker and was able to consume only small quantities of food. The patient appeared pale and cachectic. Tenderness and fullness were present in the left upper quadrant, and the spleen was palpable below the umbilicus. No hepatomegaly or peripheral adenopathy was noted.

Her laboratory results were as follows:

WBCs—248 x 10^9/L

HGB—9.5 g/dl

HCT—26.3%

Platelets—449 x10^9/L

Segmented neutrophils—44%

Band neutrophils—4%

Lymphocytes—10%

Eosinophils—3%

Basophils—7%

Myelocytes—30%

Promyelocytes—1%

Myeloblasts—1%

Nucleated RBCs—2 per 100

WBCs Reticulocytes—3%

Leukocyte alkaline phosphatase (LAP) score—20

(reference range, 40 to 130)

Lactate dehydrogenase—692 IU

(reference range, 140 to 280 IU)

Uric acid—8.1 mg/dL (reference range, 4 to 6 mg/dL)

Questions:

1. What is the significance of the elevated WBC count and abnormal WBC differential?

2. How does the LAP score aid in the diagnosis?

3. What is your diagnosis based on the presented case ?

Answer 1

1. A white blood cell (WBC) count measures the number of white blood cells in the blood, and a WBC differential determines the percentage of each type of white blood cell

present in the blood. A differential can also detect immature white blood cells and abnormalities, both of which are signs of potential issues.

WBC count and differential is done if its suspected to have one of several conditions, including:

• anemia
• infection
• leukemia

• Measurement of circulating leukocytes (white blood cells; WBC) in whole blood for the evaluation and management of
  • Primary leukocyte disorders
  • Secondary inflammatory
  • Leukocyte suppression responses to physical agents, toxins or disease
  • Myeloproliferative disorders

2. Leukocyte alkaline phosphatase (LAP) is the term for alkaline phosphatase that’s found in leukocytes. Another name for leukocytes is white blood cells. These are several types of white bloods cells. Each one has a different role in defending the body against viruses, bacteria, and other germs. They’re a crucial part of the immune system. ALP is found in different forms throughout the body. This test is done to confirm a number of different medical conditions, including certain types of anemia and leukemia.

Scores for the LAP test can range from zero to 400, with those between 20 and 100 being considered normal.

In chronic myeloid leukemia (CML), there will be less alkaline phosphatase in the white blood cells than normal.

A score that’s higher than normal may be caused by:

• leukemoid reaction
• essential thrombocytosis
• myelofibrosis
• polycythemia vera

A score that’s lower than normal may indicate:

• CML
• aplastic anemia
• pernicious anemia

3. The diagnosis based on the presented case is suggestive of acute leukemia. As there is an increase in WBC count, platelet count, elevated lactate dehydrogenase, uric acid, LAP is 20 and splenomegaly