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Question:

The following vignette applies to the next 2 items. The items in the set must be answered in sequential order.  Once you click Proceed to Next Item, you will not be able to add or change an answer.

A 32-year-old man comes to the office due to persistent fatigue.  His exercise tolerance has decreased dramatically over the past 3 weeks.  The patient has no significant past medical history.  Blood pressure is 126/72 mm Hg, and pulse is 88/min.  Physical examination shows prominent conjunctival pallor with no icterus.  Fundoscopy demonstrates small areas of retinal hemorrhages and cotton wool spots bilaterally.  White patches with an erythematous base are present on the gingival and buccal mucosa.  Lungs are clear on auscultation and heart sounds are normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Skin examination reveals scattered petechiae and ecchymoses.  No lymphadenopathy is present.

Item 1 of 2

Which of the following peripheral blood smear findings is most specific for this patient's condition?

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Explanation:

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This patient most likely has acute myeloid leukemia.  Affected individuals typically develop symptoms of pancytopenia:

  • Anemia can cause fatigue, mucosal pallor, and decreased exercise tolerance.
  • Leukopenia is associated with opportunistic infections (eg, candidiasis, aspergillosis, bacterial pneumonia).  The white patches described in this patient's oral mucosa are most likely the result of oral thrush (candidiasis).
  • Thrombocytopenia is associated with bleeding complications (eg, gingival bleeding, petechiae).

Hepatosplenomegaly and lymphadenopathy are less common than in acute lymphoblastic leukemia.  Ocular involvement is characteristic and may include cotton wool spots (due to clusters of tumor cells occluding retinal arterioles) and retinal hemorrhages.  Most patients have circulating myeloblasts, which are likely to be found on peripheral blood smear.

(Choice A)  Basophilic stippling refers to blue granules (ribosomal precipitants) spread throughout the cytoplasm of red blood cells.  Basophilic stippling is often seen in thalassemias, alcohol use disorder, and lead poisoning.

(Choice C)  Prominent eosinophilia can be observed in a number of clinical settings, including certain parasitic infections, atopic diseases, and drug reactions.

(Choice D)  Atypical lymphocytes (reactive lymphocytes) are commonly observed in viral infections and can occasionally be seen in leukemia.  However, they are not specific for leukemia.

(Choice E)  Patients with spherocytosis have red cells without central pallor on peripheral blood smear.  Spherocytosis is associated with hemolytic anemia; opportunistic infections and bleeding complications are not typically seen.

Educational objective:
Clinical features of acute myeloid leukemia are usually the result of pancytopenia.  Myeloblasts are commonly observed on peripheral blood smear.