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JAMA Clinical Challenge
July 25, 2017

Epistaxis, Ecchymoses, and an Abnormal White Blood Cell Count

Author Affiliations
  • 1Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA. 2017;318(4):383-384. doi:10.1001/jama.2017.9020

A 42-year-old man presented with spontaneous ecchymoses of the extremities for the past 2 days and spontaneous epistaxis for the past 2 hours. He had a history of gastroesophageal reflux disease and allergic rhinitis. His medications included esomeprazole, fluticasone nasal spray, and supplemental cholecalciferol. Physical examination revealed multiple ecchymoses on the extremities and abdomen but was otherwise unremarkable. Laboratory evaluation showed a white blood cell count of 2.4 × 103/µL, with 13% neutrophils, 32% lymphocytes, 1% monocytes, 0% eosinophils, 0% basophils, and 54% blasts. Hemoglobin level was 10.3 g/dL, and platelet count was 20 × 103/µL. Prothrombin time was 14.5 seconds; international normalized ratio, 1.4; partial thromboplastin time, 27 seconds; D-dimer level, 2.524 μg/mL (13.82 nmol/L); and fibrinogen level, 68 mg/dL (2 μmol/L). A peripheral blood smear was obtained (Figure).

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