Patient: A 66-year-old Caucasian male. Chief Complaint: The patient felt tired and was eating less than usual. Previously, the patient could ride his bike for 3 miles, but now can barely complete 1 mile. Medical History: Significant for persistent lymphocytosis for the past 10 years and recently diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) by flow cytometry on peripheral blood. He also has a history of hyperlipidemia, diabetes mellitus, and obstructive sleep apnea. Social History: The patient does not smoke or use illicit drugs. He uses alcohol occasionally. The patient is married and is retired from an automobile supply company. Family History: Noncontributory. None of his family members have a history of blood disorders. Physical Examination: Significant for the following: alert; oriented to time, place, and person; neck: no palpable lymphadenopathy; heart and lung: unremarkable; abdomen: obese and soft, no palpable hepatosplenomegaly. Vital signs: Blood pressure: 137/58 mmHg; pulse: 68/minute; respiratory rate: 12/minute; temperature: 37 C. Principal Laboratory Findings: Laboratory test results are in Table 1. Additional Testing: The molecular diagnostic test Janus kinase 2 (JAK2) V617F mutation was ordered. A peripheral blood smear at the hematologist's office was abnormal 3 months later. Subsequently, on the peripheral blood specimen the molecular test assessing presence of BCR/ABL1 mRNA transcript producing the 210-kDa protein (p210) was ordered and a bone marrow biopsy with aspirate was performed. The bone marrow aspirate was also submitted for morphologic, cytogenetic, and flow cytometric evaluations (Images 1 and 2).
