Cytoplasmic globules in erythroid blasts and CLL.

Panel A (3400 magnification hematoxylin and eosin) of the BM biopsy shows extensive sheets (90%) of immature large cells in a background of small lymphoid cells (arrow). Increased proerythroblasts (.25% in the touch preparation) with irregular nuclei, prominent nucleoli, and basophilic vacuolated cytoplasm were observed. Panel B demonstrates a Wright-Giemsa–stained marrow aspirate smear showing characteristic vacuolated pronormoblasts (arrows) and periodic acid-Schiff–positive cytoplasmic globules distributed in the periphery of the erythroid blasts (inset) (31000 magnification). Periodic acid-Schiff positivity is a result of glycogen deposits in the erythroblasts. Immunohistochemistry and flow cytometry confirmed the CLL and E-cadherin–positive, glycophorin-negative erythroid blasts. Cytogenetic studies of BM showed complex karyotype. A final diagnosis of therapy-related, pure erythroid leukemia with a background of CLL was made. Initial clinical features with large cells in the BM mimicked Richter’s transformation. The patient died within a few days of the diagnosis as a result of progressive disease. c Preetesh Jain and Su S. Chen, University of Texas M.D. Anderson Cancer Center