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JAMA Clinical Challenge
September 10, 2014

Weakness, Fatigue, and an Abnormal White Blood Cell Count

Author Affiliations
  • 1University of Rochester, Rochester, New York
  • 2Rochester General Hospital, Rochester, New York
JAMA. 2014;312(10):1051-1052. doi:10.1001/jama.2014.2440

During the past 2 months, a 63-year-old man developed gradually worsening weakness and fatigue. He has had occasional night sweats but reported no fevers, weight loss, or change in appetite. He had type 2 diabetes mellitus treated with insulin, metformin, glyburide, and pioglitazone. He also had coronary artery disease complicated by a myocardial infarction and coronary artery bypass graft surgery 6 years ago. The general physical examination was unrevealing, as were oropharyngeal, cardiac, respiratory, abdominal, and lymph node examinations. A complete blood cell count (CBC) showed a hemoglobin level of 14.6 g/dL and a white blood cell count of 24.1 × 103/μL with 25% neutrophils and 69% lymphocytes; platelet count was 189 × 103/μL. A peripheral blood smear (Figure) showed red blood cells with mild anisocytosis (unequal size) and poikilocytosis (variation in shape). The platelets were normal in number and appearance. White blood cells were increased, with a lymphocytic predominance. The lymphocytes were mature and appeared somewhat heterogeneous. Smudge cells were noted (Figure, Left panel, lower right corner; Right panel, center). Smudge cells are artifacts of the slide presentation and are seen in certain disease states.

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