The case is about a 31-year-old Hispanic male with Schizophrenia diagnosed at age 29. The patient had been treated with multiple medication regimens without much success to control his psychotic outbreaks. The patient was most recently started on clozapine by his psychiatrist and was subsequently scheduled for regular blood monitoring. The patient had been taking Clozapine for a total of 8 months. Routine complete blood count (CBC) was repeated every two weeks. White blood cells (WBC) trended from 6.9 x103/muL to 21.2 x103/muL in two weeks. On the next routine CBC, WBC spiked to 104x103/muL. (See Table 1) This prompted the psychiatrist to send the patient to Emergency department for further evaluation.
Upon admission, review of systems was positive only for vague generalized weakness and fatigue for the past "few" months. Patient denied any fever, chills, night sweats, weight loss, sore throat, cough, chest pain, SOB, abdominal pain, nausea, vomiting, or changes in bowel movements. He also denied any rash or bleeding from his gums. There is no family history of malignancy. Physical exam was significant only for obesity and tender cervical lymphadenopathy noted on the right.
Laboratory was significant for hyperleukocytosis with WBC 104x103/muL (normal range: 4.5-11x103/muL). Differentials were 78% atypical lymphocytes, 10% lymphocytes, 3% blasts (Figure 1), 4% neutrophils, 2% bands, 1% monocytes, 2% eosinophils (See Table 1 for 10-week trend). Laboratory was also significant for mildly elevated LDH 289 unit/L (normal range: 140-271 unit/L) and new-onset thrombocytopenia and normocytic anemia. HIV was negative. Peripheral blood Flow cytometry analysis showed 85% of the cells consisting of TdT+, CD34+ B cell lymphoblasts; consistent with the diagnosis of B cell ALL (See Table 2).