SUMMARY: Yetgin S, Kuşkonmaz B, Aytaç S, Çetin M. The evaluation of acquired aplastic anemia in c... more SUMMARY: Yetgin S, Kuşkonmaz B, Aytaç S, Çetin M. The evaluation of acquired aplastic anemia in children and unexpected frequency of varicella-zoster virus association: a single-center study. Turk J Pediatr 2008; 50: 342-348. In this study, 32 patients under the age of 17 years with acquired aplastic anemia (AAA) were evaluated. Nine patients developed AAA associated with viral infection in
Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in ... more Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in children. We describe herein a child who developed CIAE with bullous formation following high-dose methotrexate and cytarabine for relapsed acute lymphoblastic leukemia. The rash completely resolved within two weeks of the appearance without any specific treatment. CIAE may develop in children with hematological malignancies as a complication of
We describe herein four children with acute lymphoblastic leukemia who were diagnosed as pulmonar... more We describe herein four children with acute lymphoblastic leukemia who were diagnosed as pulmonary fungal infection after presenting with chest pain. The plain radiologic evaluations failed to reveal any positive findings, whereas computerized tomography (CT) scanning showed nodular opacification with or without cavitation. This experience suggests that chest pain may be an initial symptom of an invasive fungal infection in patients with leukemia, and CT scan of the lungs should be performed urgently for the early diagnosis and treatment, despite normal plain X-rays.
Infection has an important role in the pathogenesis of thrombosis and it becomes more prominent i... more Infection has an important role in the pathogenesis of thrombosis and it becomes more prominent in childhood cases, in whom the infection frequency is higher. It has been suggested that patients with high tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 levels might be at increased risk of developing thrombotic complications owing to the effects of these cytokines on the coagulation pathway. Functional polymorphisms in the promoter regions of the genes coding for TNF-alpha and IL-6 are associated with increased plasma levels of these cytokines. The aims of this study were to evaluate the serum levels of acute phase reactants, such as C-reactive protein, and of cytokines (TNF-alpha and IL-6) and to investigate the association between the TNF-alpha-308 G/A and IL-6-174 G/C polymorphisms in Turkish pediatric patients with thrombosis. Fifty-eight children with thrombosis (group 1) and 89 controls (group 2) were included in the study. Patients who had a history of infection withi...
Peripheral blood smears of 43 patients (26 males, median age 18 months, range: 6-180 months) with... more Peripheral blood smears of 43 patients (26 males, median age 18 months, range: 6-180 months) with nutritional iron-deficiency anemia (IDA) were examined for the presence of trilineage hematological dysplasia. Twelve patients were reexamined for dysplastic findings after achieving a normal Hb and hematocrit level for age by the end of 2-3 months of iron treatment. A control group of 17 age-matched healthy children were also included. Neutrophils with loss of membrane entirety and protrusions were remarkable in 34/43 (79%) in the IDA group versus 1/12 (8%) after iron treatment and none of the control group. Microspherocytes were seen in 9/43 (21%) of IDA patients. Additionally, trilienage dysplasia was observed in the bone marrow samples available in 3 of the patients. It has been shown that iron-deficiency results in cellular DNA and RNA alterations, cell-cycle G1/S phase arrest, and apoptosis. Rac GTPases have been shown to control actin cytoskeleton, influencing cell polarity, micr...
In this pilot study, 30 (14 male, 16 female; median age: 8 years, range: 2-18) chronic non-splene... more In this pilot study, 30 (14 male, 16 female; median age: 8 years, range: 2-18) chronic non-splenectomized idiopathic thrombocytopenic purpura (ITP) patients with Rh+ blood group and their 49 attacks were evaluated after intravenous (i.v.) anti-D (WinRho SDF, Cangene Corporation, Winnipeg, MB, Canada) treatment at a dose of 50 microg/kg x 3 days (n = 21 cases; 35 attacks) or a single dose of 75 microg/kg (n = 9 cases; 14 attacks) to define the hemostatic dose of anti-D. Five of 30 patients (22/49 attacks) were resistant to steroid, intravenous immunoglobulin (IVIG) and vincristine treatment. Hemoglobin (Hb), white blood cells (WBC), platelets (plt) and reticulocytes (ret) were evaluated before and after treatment during the follow-up in sequences on the 1st, 7th, 14th and 21st days after anti-D treatment if the patients had no symptom. All patients, even the resistant ones, experienced an increase in plt count to provide protection from bleeding (> or = 20 x 10(9)/L in patients wi...
Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in ... more Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in children. We describe herein a child who developed CIAE with bullous formation following high-dose methotrexate and cytarabine for relapsed acute lymphoblastic leukemia. The rash completely resolved within two weeks of the appearance without any specific treatment. CIAE may develop in children with hematological malignancies as a complication of pediatric chemotherapeutic regimens, and pediatricians should be aware of this phenomenon despite its rarity.
Hematologic malignancies including acute leukemias rarely associate with cystic fibrosis (CF). In... more Hematologic malignancies including acute leukemias rarely associate with cystic fibrosis (CF). In this paper, we describe a case who was diagnosed with CF when she was three months old and presented with acute myelogenous leukemia (AML) at the age of 17 years. Although she received reduced doses of chemotherapy because of her clinical status she responded well. She is the first CF patient who developed AML in our department among 296 CF patients over a 22-year period.
We reviewed the pattern of acute and long-term (during and after treatment period) neurologic com... more We reviewed the pattern of acute and long-term (during and after treatment period) neurologic complications in children with acute lymphoblastic leukemia (ALL). Among 265 patients, 40 developed neurotoxicity. Twenty-one and 19 of the patients were treated with St. Jude Total XI and St. Jude Total XIII chemotherapy protocols, respectively. There was no difference between Total XI and XIII chemotherapy protocol groups in neurotoxicity. Neurological symptoms were determined during the therapy period in 33 (82.5%) and in the late period in 7 (15%) of 40 patients. Systemic chemotherapy (including vincristine, high-dose methotrexate) and intrathecal chemotherapy seem to be the most common predisposing factors. In the study group, neurological complications in two patients were iatrogenic as a result of lumbar puncture (1 case) and due to erroneous vincristine administration on two consecutive days (1 case).
Current tests for evaluation of vitamin B(12) absorption are problematic because they involve the... more Current tests for evaluation of vitamin B(12) absorption are problematic because they involve the use of radioactively labeled vitamin B(12). We describe a vitamin B(12) absorption test that circumvents this problem. We measured cobalamin or transcobalamin saturated with cobalamin (holo-TC) 24 h after three 9-microg doses of vitamin B(12) given orally at 6-h intervals. We studied 17 patients with inherited malabsorption of vitamin B(12) attributable to Imerslund-Grasbeck syndrome (n = 13) or intrinsic factor deficiency (n = 4), their obligate heterozygous biological parents (n = 19), and healthy controls (n = 44). In the patients, the median (range) change of holo-TC after the B(12) load was not significant [1 (-42 to 5) pmol/L], nor was the change of cobalamin [-3 (-32 to 22) pmol/L], consistent with a lack of measurable active or passive absorption. In controls, however, the median (range) increases of holo-TC and cobalamin were 26 (-6 to 63) pmol/L and 41 (-37 to 109) pmol/L, res...
In this retrospective study, we report the results of antifungal treatments (AFTs) in febrile neu... more In this retrospective study, we report the results of antifungal treatments (AFTs) in febrile neutropenic episodes in patients with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML) and aplastic anemia (AA) in our center. From January 2004 to December 2005, a total of 52 patients and 221 febrile neutropenic episodes were evaluated. AFT was started in 96 (43%) of the 221 episodes. Amphotericin B and fluconazole were used in 44 (46%) and 52 (54%) febrile neutropenic episodes, respectively. Microbiologically or histopathologically evident fungal infections were detected in 35 of 96 febrile neutropenic episodes. The mortality rate due to fungal infection was higher in patients with AA (7/8 patients) and AML (7/12 patients) than in ALL patients (1/32). Mortality for the whole group was 28%. When the mortality rate was compared between the two treatment groups (amphotericin B vs fluconazole), mortality was significantly higher in patients receiving amphotericin B [n = 14 (9...
Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomeg... more Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomegaly, and immature circulating white blood cells, and affects approximately 10 % of neonates with Down syndrome. The authors report a neonate with Down syndrome who developed acute widespread pustular eruptions as a sign of TMD. The white blood cell counts on the first day of life were markedly elevated, with blasts seen on examination of the peripheral blood smear. And the patient was noted to have a few erythematous papules and pustules especially on the face. On the following days pathergy positive crusted papules and pustules were increased and spread to trunk and extremities. Skin biopsy specimens showed pustular dermatitis, with subcorneal vesiculopustules and perivascular inflammation in superficial dermis. These lesions improved parallel with the hematologic improvement within two weeks. The authors aim to alert clinicians about this uncommon cause of vesiculopustular eruption with the present illustrative case and review the literature.
D56. PEDIATRIC CASE REPORTS: DIAGNOSTIC AND MANAGEMENT DILEMMAS, 2010
... Five cases, diagnosed as eosinophilic lung diseases at Hacettepe University Ihsan Dogramacı ... more ... Five cases, diagnosed as eosinophilic lung diseases at Hacettepe University Ihsan Dogramacı Childrens' Hospital, are reviewed: one idiopathic acute eosinophilic pneumonia (IAEP), three idiopathic chronic eosinophilic pneumonia (ICEP), and one idiopathic ...
The aim of this study was to describe the incidence and contributory risk factors for thromboembo... more The aim of this study was to describe the incidence and contributory risk factors for thromboembolic complications in children with nephrotic syndrome (NS) and thrombosis. Among 188 children with the diagnosis of NS (80 girls; mean age: 12.6 ± 5.4 years) followed up in our hospital for the last 5 years, 17 (9.0 %) children (16 boys) identified as having thromboembolic complications. All 17 children with NS and thrombosis were screened for laboratory risk factors for thrombosis. The diagnosis was confirmed by cranial magnetic resonance imaging, doppler ultrasonography, and echocardiography. Among 17 children with thrombosis, 14 (82.3 %) were found to have focal segmental glomerulosclerosis (FSGS) as underlying pathology by renal biopsy. The mean age of the thrombotic children was 4.5 ± 3.2 years at the diagnosis of NS and that was 7.1 ± 4.9 years at the time of thrombosis. The mean time from NS diagnosis to the first thrombosis development was 2.6 ± 2.3 years. Thrombosis occurred during the first year of NS in 9/17 (52.9 %) children. Most of the children (88.2 %) had venous thrombosis. Among the screened risk factors, high factor VIII level (64.7 %) was the leading factor followed by decreased antithrombin III level (29.4 %). Furthermore, 4 children had central venous catheters and 2 had infection as clinical risk factors for thrombosis. In this case series, subtype of FSGS, active disease state of NS, central venous catheters, and some inherited and acquired thrombotic risk factors have been identified as contributory factors for the development of thrombosis in children with NS.
Herein we report a sixteen-year-old female that developed deep vein thrombosis (DVT) while underg... more Herein we report a sixteen-year-old female that developed deep vein thrombosis (DVT) while undergoing treatment for H1N1 pneumonia. To the best of our knowledge this is the first report of H1N1/09 infection complicated by DVT in an adolescent patient with no detected risk factors other than immobilization. Healthcare providers should be aware of the possibility of thrombosis in patients with swine-origin influenza, especially in those with additional risk factors.
The diagnosis of acute leukemia is based on a combination of clinical, hematological, morphologic... more The diagnosis of acute leukemia is based on a combination of clinical, hematological, morphological, cytogenetic, and immunophenotypic data. The authors report a case of reactive lymphocytosis with extremely elevated lymphocytic and lymphoblastic leukocytosis that mimicked acute lymphoblastic leukemia, not only morphologically, but also in immunophenotypic analysis. They could not determine any underlying disease marker other than infectious symptoms that were present for 20 days prior to presentation to their clinic. Although this case presented with extremely high lymphocytic leukocytosis, the patient had normal blood cell lineage, a moderate level of blastic cells in bone marrow, and normal physical findings. These findings convinced the authors to follow up the patient before beginning treatment.
SUMMARY: Yetgin S, Kuşkonmaz B, Aytaç S, Çetin M. The evaluation of acquired aplastic anemia in c... more SUMMARY: Yetgin S, Kuşkonmaz B, Aytaç S, Çetin M. The evaluation of acquired aplastic anemia in children and unexpected frequency of varicella-zoster virus association: a single-center study. Turk J Pediatr 2008; 50: 342-348. In this study, 32 patients under the age of 17 years with acquired aplastic anemia (AAA) were evaluated. Nine patients developed AAA associated with viral infection in
Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in ... more Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in children. We describe herein a child who developed CIAE with bullous formation following high-dose methotrexate and cytarabine for relapsed acute lymphoblastic leukemia. The rash completely resolved within two weeks of the appearance without any specific treatment. CIAE may develop in children with hematological malignancies as a complication of
We describe herein four children with acute lymphoblastic leukemia who were diagnosed as pulmonar... more We describe herein four children with acute lymphoblastic leukemia who were diagnosed as pulmonary fungal infection after presenting with chest pain. The plain radiologic evaluations failed to reveal any positive findings, whereas computerized tomography (CT) scanning showed nodular opacification with or without cavitation. This experience suggests that chest pain may be an initial symptom of an invasive fungal infection in patients with leukemia, and CT scan of the lungs should be performed urgently for the early diagnosis and treatment, despite normal plain X-rays.
Infection has an important role in the pathogenesis of thrombosis and it becomes more prominent i... more Infection has an important role in the pathogenesis of thrombosis and it becomes more prominent in childhood cases, in whom the infection frequency is higher. It has been suggested that patients with high tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 levels might be at increased risk of developing thrombotic complications owing to the effects of these cytokines on the coagulation pathway. Functional polymorphisms in the promoter regions of the genes coding for TNF-alpha and IL-6 are associated with increased plasma levels of these cytokines. The aims of this study were to evaluate the serum levels of acute phase reactants, such as C-reactive protein, and of cytokines (TNF-alpha and IL-6) and to investigate the association between the TNF-alpha-308 G/A and IL-6-174 G/C polymorphisms in Turkish pediatric patients with thrombosis. Fifty-eight children with thrombosis (group 1) and 89 controls (group 2) were included in the study. Patients who had a history of infection withi...
Peripheral blood smears of 43 patients (26 males, median age 18 months, range: 6-180 months) with... more Peripheral blood smears of 43 patients (26 males, median age 18 months, range: 6-180 months) with nutritional iron-deficiency anemia (IDA) were examined for the presence of trilineage hematological dysplasia. Twelve patients were reexamined for dysplastic findings after achieving a normal Hb and hematocrit level for age by the end of 2-3 months of iron treatment. A control group of 17 age-matched healthy children were also included. Neutrophils with loss of membrane entirety and protrusions were remarkable in 34/43 (79%) in the IDA group versus 1/12 (8%) after iron treatment and none of the control group. Microspherocytes were seen in 9/43 (21%) of IDA patients. Additionally, trilienage dysplasia was observed in the bone marrow samples available in 3 of the patients. It has been shown that iron-deficiency results in cellular DNA and RNA alterations, cell-cycle G1/S phase arrest, and apoptosis. Rac GTPases have been shown to control actin cytoskeleton, influencing cell polarity, micr...
In this pilot study, 30 (14 male, 16 female; median age: 8 years, range: 2-18) chronic non-splene... more In this pilot study, 30 (14 male, 16 female; median age: 8 years, range: 2-18) chronic non-splenectomized idiopathic thrombocytopenic purpura (ITP) patients with Rh+ blood group and their 49 attacks were evaluated after intravenous (i.v.) anti-D (WinRho SDF, Cangene Corporation, Winnipeg, MB, Canada) treatment at a dose of 50 microg/kg x 3 days (n = 21 cases; 35 attacks) or a single dose of 75 microg/kg (n = 9 cases; 14 attacks) to define the hemostatic dose of anti-D. Five of 30 patients (22/49 attacks) were resistant to steroid, intravenous immunoglobulin (IVIG) and vincristine treatment. Hemoglobin (Hb), white blood cells (WBC), platelets (plt) and reticulocytes (ret) were evaluated before and after treatment during the follow-up in sequences on the 1st, 7th, 14th and 21st days after anti-D treatment if the patients had no symptom. All patients, even the resistant ones, experienced an increase in plt count to provide protection from bleeding (> or = 20 x 10(9)/L in patients wi...
Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in ... more Chemotherapy-induced acral erythema (CIAE) with bullous formation is an uncommon complication in children. We describe herein a child who developed CIAE with bullous formation following high-dose methotrexate and cytarabine for relapsed acute lymphoblastic leukemia. The rash completely resolved within two weeks of the appearance without any specific treatment. CIAE may develop in children with hematological malignancies as a complication of pediatric chemotherapeutic regimens, and pediatricians should be aware of this phenomenon despite its rarity.
Hematologic malignancies including acute leukemias rarely associate with cystic fibrosis (CF). In... more Hematologic malignancies including acute leukemias rarely associate with cystic fibrosis (CF). In this paper, we describe a case who was diagnosed with CF when she was three months old and presented with acute myelogenous leukemia (AML) at the age of 17 years. Although she received reduced doses of chemotherapy because of her clinical status she responded well. She is the first CF patient who developed AML in our department among 296 CF patients over a 22-year period.
We reviewed the pattern of acute and long-term (during and after treatment period) neurologic com... more We reviewed the pattern of acute and long-term (during and after treatment period) neurologic complications in children with acute lymphoblastic leukemia (ALL). Among 265 patients, 40 developed neurotoxicity. Twenty-one and 19 of the patients were treated with St. Jude Total XI and St. Jude Total XIII chemotherapy protocols, respectively. There was no difference between Total XI and XIII chemotherapy protocol groups in neurotoxicity. Neurological symptoms were determined during the therapy period in 33 (82.5%) and in the late period in 7 (15%) of 40 patients. Systemic chemotherapy (including vincristine, high-dose methotrexate) and intrathecal chemotherapy seem to be the most common predisposing factors. In the study group, neurological complications in two patients were iatrogenic as a result of lumbar puncture (1 case) and due to erroneous vincristine administration on two consecutive days (1 case).
Current tests for evaluation of vitamin B(12) absorption are problematic because they involve the... more Current tests for evaluation of vitamin B(12) absorption are problematic because they involve the use of radioactively labeled vitamin B(12). We describe a vitamin B(12) absorption test that circumvents this problem. We measured cobalamin or transcobalamin saturated with cobalamin (holo-TC) 24 h after three 9-microg doses of vitamin B(12) given orally at 6-h intervals. We studied 17 patients with inherited malabsorption of vitamin B(12) attributable to Imerslund-Grasbeck syndrome (n = 13) or intrinsic factor deficiency (n = 4), their obligate heterozygous biological parents (n = 19), and healthy controls (n = 44). In the patients, the median (range) change of holo-TC after the B(12) load was not significant [1 (-42 to 5) pmol/L], nor was the change of cobalamin [-3 (-32 to 22) pmol/L], consistent with a lack of measurable active or passive absorption. In controls, however, the median (range) increases of holo-TC and cobalamin were 26 (-6 to 63) pmol/L and 41 (-37 to 109) pmol/L, res...
In this retrospective study, we report the results of antifungal treatments (AFTs) in febrile neu... more In this retrospective study, we report the results of antifungal treatments (AFTs) in febrile neutropenic episodes in patients with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML) and aplastic anemia (AA) in our center. From January 2004 to December 2005, a total of 52 patients and 221 febrile neutropenic episodes were evaluated. AFT was started in 96 (43%) of the 221 episodes. Amphotericin B and fluconazole were used in 44 (46%) and 52 (54%) febrile neutropenic episodes, respectively. Microbiologically or histopathologically evident fungal infections were detected in 35 of 96 febrile neutropenic episodes. The mortality rate due to fungal infection was higher in patients with AA (7/8 patients) and AML (7/12 patients) than in ALL patients (1/32). Mortality for the whole group was 28%. When the mortality rate was compared between the two treatment groups (amphotericin B vs fluconazole), mortality was significantly higher in patients receiving amphotericin B [n = 14 (9...
Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomeg... more Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomegaly, and immature circulating white blood cells, and affects approximately 10 % of neonates with Down syndrome. The authors report a neonate with Down syndrome who developed acute widespread pustular eruptions as a sign of TMD. The white blood cell counts on the first day of life were markedly elevated, with blasts seen on examination of the peripheral blood smear. And the patient was noted to have a few erythematous papules and pustules especially on the face. On the following days pathergy positive crusted papules and pustules were increased and spread to trunk and extremities. Skin biopsy specimens showed pustular dermatitis, with subcorneal vesiculopustules and perivascular inflammation in superficial dermis. These lesions improved parallel with the hematologic improvement within two weeks. The authors aim to alert clinicians about this uncommon cause of vesiculopustular eruption with the present illustrative case and review the literature.
D56. PEDIATRIC CASE REPORTS: DIAGNOSTIC AND MANAGEMENT DILEMMAS, 2010
... Five cases, diagnosed as eosinophilic lung diseases at Hacettepe University Ihsan Dogramacı ... more ... Five cases, diagnosed as eosinophilic lung diseases at Hacettepe University Ihsan Dogramacı Childrens' Hospital, are reviewed: one idiopathic acute eosinophilic pneumonia (IAEP), three idiopathic chronic eosinophilic pneumonia (ICEP), and one idiopathic ...
The aim of this study was to describe the incidence and contributory risk factors for thromboembo... more The aim of this study was to describe the incidence and contributory risk factors for thromboembolic complications in children with nephrotic syndrome (NS) and thrombosis. Among 188 children with the diagnosis of NS (80 girls; mean age: 12.6 ± 5.4 years) followed up in our hospital for the last 5 years, 17 (9.0 %) children (16 boys) identified as having thromboembolic complications. All 17 children with NS and thrombosis were screened for laboratory risk factors for thrombosis. The diagnosis was confirmed by cranial magnetic resonance imaging, doppler ultrasonography, and echocardiography. Among 17 children with thrombosis, 14 (82.3 %) were found to have focal segmental glomerulosclerosis (FSGS) as underlying pathology by renal biopsy. The mean age of the thrombotic children was 4.5 ± 3.2 years at the diagnosis of NS and that was 7.1 ± 4.9 years at the time of thrombosis. The mean time from NS diagnosis to the first thrombosis development was 2.6 ± 2.3 years. Thrombosis occurred during the first year of NS in 9/17 (52.9 %) children. Most of the children (88.2 %) had venous thrombosis. Among the screened risk factors, high factor VIII level (64.7 %) was the leading factor followed by decreased antithrombin III level (29.4 %). Furthermore, 4 children had central venous catheters and 2 had infection as clinical risk factors for thrombosis. In this case series, subtype of FSGS, active disease state of NS, central venous catheters, and some inherited and acquired thrombotic risk factors have been identified as contributory factors for the development of thrombosis in children with NS.
Herein we report a sixteen-year-old female that developed deep vein thrombosis (DVT) while underg... more Herein we report a sixteen-year-old female that developed deep vein thrombosis (DVT) while undergoing treatment for H1N1 pneumonia. To the best of our knowledge this is the first report of H1N1/09 infection complicated by DVT in an adolescent patient with no detected risk factors other than immobilization. Healthcare providers should be aware of the possibility of thrombosis in patients with swine-origin influenza, especially in those with additional risk factors.
The diagnosis of acute leukemia is based on a combination of clinical, hematological, morphologic... more The diagnosis of acute leukemia is based on a combination of clinical, hematological, morphological, cytogenetic, and immunophenotypic data. The authors report a case of reactive lymphocytosis with extremely elevated lymphocytic and lymphoblastic leukocytosis that mimicked acute lymphoblastic leukemia, not only morphologically, but also in immunophenotypic analysis. They could not determine any underlying disease marker other than infectious symptoms that were present for 20 days prior to presentation to their clinic. Although this case presented with extremely high lymphocytic leukocytosis, the patient had normal blood cell lineage, a moderate level of blastic cells in bone marrow, and normal physical findings. These findings convinced the authors to follow up the patient before beginning treatment.
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