I’ve learned many lessons throughout fellowship. One of the most valuable has been recognizing the importance of regular collaboration among the members of a patient’s care team. No matter how engrossed we become in our own work, teaming up with other healthcare professionals can help ensure an accurate diagnosis and improve quality of care.
In this article, I present the case of a woman with chronic pancytopenia and a “normal bone marrow biopsy” felt to be related to rheumatoid arthritis (RA) and immunosuppression. However, a visit to the pathology department two years after the initial diagnosis revealed something quite different. Cases such as this one serve as a reminder to us all about the importance of working together with others as part of a team-based approach.
Patient Case Explored
Our patient is a 62-year-old woman with a past medical history of RA, hypertension, and hypothyroidism. This patient was initially seen in August of 2013 by one of our oncologists. During the initial evaluation, it was noted that she was being treated for chronic immunosuppression for active RA with prednisone (10 mg daily) and etanercept. Her complete blood count showed leukopenia 1200/mcL, neutropenia with an absolute neutrophil count of 300/mcL, and thrombocytopenia 55,000/mcL.
The patient’s physical examination revealed mild to moderate splenomegaly; a computed tomography scan of her chest, abdomen, and pelvis came back negative; and a bone marrow biopsy looked fairly normal except for increased cellularity relative to her age. Her hematologist assumed that she did not have a bone marrow disorder and attributed her pancytopenia to her autoimmune disease and immunosuppression. Based on his assessment, the hematologist began treating her with growth factors and transfused blood products on an as-needed basis.
In November of 2015, she presented to the hospital with a gangrenous finger attributed to vasculitis. At this visit, she was found to have worsening pancytopenia with a white blood cell count of 600/mcL, hemoglobin of 10.7 g/dL, and platelets of 61,000/mcL.
My team and I began putting all of the pieces to this puzzle together. Based on her previous diagnosis of RA, splenomegaly, and pancytopenia, we began to strongly consider that she may have large granulocytic leukemia (LGL). LGL is a chronic type of leukemia that is more common in the western world and is characterized by pancytopenia and splenomegaly, and sometimes fever or weight loss. Notably, LGL is usually associated with autoimmune disease.
Based on my suspicion, I performed another bone marrow biopsy and specified an order to evaluate for LGL. To make sure that the pathologist was aware of my patient’s health history, I went to the department and reviewed the case further. Sure enough, the pathology report revealed CD57+CD8+CD4- T cells consistent with LGL. The pathologist was very grateful that I had pursued the case so diligently, as she explained to me that LGL is commonly missed if there is no suspicion for it.
I notified the patient’s oncologist right away and together we discussed this new diagnosis and the treatment options that would be most appropriate. We decided on a treatment plan that involved a long-term, slow tapering of the patient’s steroid along with weekly methotrexate and growth factors, as needed.
Cases such as this one highlight an important principle in oncology. We frequently talk about physician communication and tumor boards; yet often, we merely read the reports and notes when making clinical decisions. This case clearly demonstrates the importance of communication and working as a team to reach the right diagnosis.
Always remember that “If it looks like a duck and walks like a duck, it is a duck.” Do not hesitate to discuss your thoughts with other providers. Our case was a slam dunk after finally detecting our patient’s LGL. Initially, the diagnosis was missed because the potential for LGL was not considered and discussed with a pathologist.
Faisal Musa, MD, is an oncology and hematology fellow at the University of Florida Health Cancer Center of Orlando Health in Orlando, FL.