A 43 year old man presented with shortness of breath and palpitation for two weeks having lost 5 kg in weight over the previous two months. There was no drug history of note. On examination, he had no lymphadenopathy or organomegaly. His haemoglobin was 42 g/litre, white cell count was 5.1 × 109/litre, lymphocytes were 1.36 × 109/litre, platelets were 497 × 109/litre, mean corpuscular volume was 105 fl, and the reticulocyte count was 2.4×109/litre (normal range, 50–200 × 109/litre). Autoimmune screen (antinuclear, nucleolar, mitochondrial, smooth muscle, and gastric parietal cell antibody) and cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies were negative.
A direct antiglobulin test was negative and vitamin B12 and folate values were normal. Serum erythropoietin was 7876 mIU/ml (normal range, 2.5–10.5). The erythrocyte sedimentation rate was 19 mm/hour. Iron studies and thyroid function tests were normal. Total bilirubin was 4 μmol/litre (normal range, 3–18) and lactate dehydrogenase was 506 U/litre (normal range, 360–720). Parvovirus IgM, human immunodeficiency virus, hepatitis B virus, and hepatitis C virus screens were negative. Paroxysmal nocturnal haemoglobinuria screening by peripheral blood flow cytometry after labelling with anti-CD55/59 was normal. A computerised tomography scan of the chest did not show a thymic mass. Oesophagogastroduodenoscopy showed a prepyloric ulcer and the patient had a positive CLO test. There was no evidence of coeliac disease in the biopsies.
A morphological examination of the bone marrow aspirate showed the absence of erythroid precursors, with 89% myeloid cells and 11% lymphocytes, none of which had LGL morphology. Flow cytometry revealed that 92% of the lymphocytes were T cells (CD3/4, +28%; CD3/8+, 63%; CD3+HLADR+, 38%) and 1.5% were B cells. Haematoxylin and eosin and Giemsa stained bone marrow biopsy (1.9 cm in length) sections showed the absence of erythroid precursors, no obvious diffuse increase of lymphocytes (fig 1A), and two lymphocytic aggregates, the largest measuring approximately 0.025 mm2
. Lymphocytes appeared to be extending from the aggregates into the surrounding bone marrow (fig 1B). Immunocytochemical staining was performed on sections of the patient’s Bouin’s fluid fixed bone marrow trephine biopsy using anti-CD3, anti-CD4, anti-CD8, anti-CD20, anti-granzyme B, and anti-glycophorin A monoclonal antibodies with avidin–biotin visualisation in an automated immunocytochemical analyser. The diffusely scattered positive cells were counted as described previously.2
In brief, the visual field area of the ×25 objective of the light microscope used was 0.26 mm2
; the positive cells in four consecutive fields of representative areas were counted. Figure 1C shows the pronounced diffuse increase in CD3+ T cells (CD3, ~ 1200/mm3
; CD4, ~ 73/mm3
; CD8, ~ 970/mm3
; granzyme B+, ~ 48/mm3
). CD 20+ cells were ~ 11/mm3
and very occasional groups of two to three glycophorin A+ erythroblasts were present. T cell receptor gene rearrangement (β and γ) was not demonstrated using primers and a gene scanning technique described previously.7
Figure 1 (A) Haematoxylin and eosin (H&E) stained section of bone marrow biopsy. (B) Lymphocytic aggregate in H&E stained section. (C) Anti-CD3 immunostained section.
Our patient was treated with prednisolone at 1 mg/kg/day with a good response: his haemoglobin rose rapidly to 128 g/litre. His haemoglobin value is currently maintained on 10 mg of prednisolone daily, although attempts to reduce this further resulted in a drop in haemoglobin. Peripheral blood lymphocyte immunophenotyping after the initiation of prednisolone treatment showed activated T cells. The white blood cell count was 6.7 × 109/litre, 14% of which were lymphocytes. Flow cytometry showed that 90% of his lymphocytes were CD3+ (CD3/4+, 47%; CD3/8+, 42%; CD3/26+, 55%; CD3+HLADR+, 20%). He received triple therapy to eradicate Helicobacter pylori.