C H A P T E R 1 3   Hematopathology of White Blood Cells 185

11 A 39-year-old woman felt a lump in her breast 1 week Hodgkin lymphoma, nodular sclerosing type
C
ago. On physical examination, she has a firm, fixed, irregular Lymphoblastic lymphoma
D
3-cm mass in the upper outer quadrant of the right breast and Mantle cell lymphoma
E
a firm, nontender lymph node in the right axilla. A lumpec- Small lymphocytic lymphoma
F
tomy and axillary node dissection are performed, and micro-
scopic examination shows an infiltrating ductal carcinoma 15 A 70-year-old man has experienced increasing fatigue
in the breast. Flow cytometric analysis of the node shows a for the past 6 months. On physical examination, he has non-
polyclonal population of CD3+, CD19+, CD20+, and CD68+ tender axillary and cervical lymphadenopathy, but there is no
cells with no aneuploidy. Microscopic examination of the axil- hepatosplenomegaly. The CBC shows hemoglobin, 9.5 g/dL;
lary lymph node is most likely to reveal changes characteristic hematocrit, 28%; MCV, 90 μm3; platelet count, 120,000/mm3;
of which of the following conditions? and WBC count, 42,000/mm3. His peripheral blood smear
Acute lymphadenitis
A shows a monotonous population of small, round, mature-
Diffuse large B-cell lymphoma
B looking lymphocytes. Flow cytometry shows these cells to
Metastatic infiltrating ductal carcinoma
C be CD19+, CD5+, and deoxynucleoti­dyl transferase negative
Necrotizing granulomas
D (TdT−). Cytogenetic and molecular analysis of the abnormal
Plasmacytosis
E cells in his blood are most likely to reveal which of the following
Sinus histiocytosis
F alterations?
Sézary syndrome
G A Clonal rearrangement of immunoglobulin genes
B Clonal rearrangement of T-cell receptor genes
12 A 9-year-old, otherwise healthy girl has complained of C t(8;14) leading to c-MYC overexpression
pain in the right armpit for the past week. Examination shows D t(9;22) leading to BCR-ABL rearrangement
tender, enlarged lymph nodes in the right axillary region. E t(14;18) leading to BCL2 overexpression
There are four linear and nearly healed abrasions over a 3 ×   
2 cm area of the distal ventral aspect of the right forearm and
a single, 0.5-cm, slightly raised erythematous nodule over one
of the abrasions. No other abnormalities are noted. Histologic
examination of one of the lymph nodes shows stellate, necro-
tizing granulomas. The lymphadenopathy regresses over the
next 2 months. Infection with which of the following is most
likely to have produced these findings?
A
Bartonella henselae
Cytomegalovirus
B
Epstein-Barr virus
C
D
Staphylococcus aureus
E
Yersinia pestis

13 A study of persons with lymphoid malignancies reveals

that there are risk factors for development of B-cell non-Hodgkin
lymphomas. Which of the following is the most likely inherited
condition predisposing to lymphoid malignancies?
Cystic fibrosis
A 16 A 69-year-old man notices the presence of lumps in
Hereditary spherocytosis
B the right side of his neck that have been enlarging for the
Sickle cell disease
C past year. Physical examination shows firm, nontender pos-
Von Willebrand disease
D terior cervical lymph nodes 1 to 2 cm in diameter. The over-
Wiskott-Aldrich syndrome
E lying skin is intact and not erythematous. A lymph node is
biopsied and the microscopic appearance is shown in the
14 A 14-year-old boy complains of discomfort in his chest figure. Molecular analysis of the DNA extracted from the
that has worsened over the past 5 days. On physical examina- cells reveals B cell receptor gene rearrangements. Which of
tion, he has generalized lymphadenopathy. A chest radiograph the following features provides the best evidence for malig-
shows clear lung fields, but there is widening of the medias- nant lymphoma in this node?
tinum. A chest CT scan shows a 10-cm mass in the anterior Absence of a pattern of lymphoid follicles with
A 
mediastinum. A biopsy specimen of the mass is obtained and germinal centers
microscopically shows effacement by lymphoid cells with Diminished sinusoidal plasma cells and
B 
lobulated nuclei having delicate, finely stippled, nuclear chro- immunoblasts
matin. There is scant cytoplasm, and many mitotic figures are Presence of CD30+ large, multinucleated cells
C 
seen. The cells express deoxynucleoti­dyl transferase negative Uniform expression of kappa, but not lambda, light
D 
(TdT−), CD2, and CD7 antigens. Molecular analysis reveals a chains in the lymphoid cells
point mutation in the NOTCH1 gene. The oncologist tells the Proliferation of small capillaries in the medullary
E 
parents that chemotherapy can be curative in vast majority of and paracortical regions
such cases. What is the most likely diagnosis?
Burkitt lymphoma
A
Follicular lymphoma
B
186 U N I T I I   Diseases of Organ Systems

17 A 4-year-old boy has appeared listless during the

past week. He exhibits irritability when his arms or legs are
touched. In the past 2 days, large ecchymoses have appeared
on the right thigh and left shoulder. CBC shows hemoglobin,
9.3 g/dL; hematocrit, 28.7%; MCV, 96 μm3; platelet count,
45,000/mm3; and WBC count, 13,990/mm3. Examination of
the peripheral blood smear shows blasts that lack peroxidase-
positive granules, but contain PAS-positive aggregates and
stain positively for deoxynucleoti­ dyl transferase negative
(TdT−). Flow cytometry shows the phenotype of blasts to be
CD19+, CD3−, and sIg−. Which of the following is the most
likely diagnosis?
Acute lymphoblastic leukemia
A
Acute myelogenous leukemia
B
Chronic lymphocytic leukemia
C
Chronic myelogenous leukemia
D
Idiopathic thrombocytopenic purpura
E 20 The figure skater Sonja Henie, who won gold medals
at the 1928, 1932, and 1936 Winter Olympic Games, became
18 A 7-year-old boy has complained of a severe headache progressively fatigued in her late 50s. On physical examina-
for the past week. On physical examination, there is tender- tion, she had palpable nontender axillary and inguinal lymph
ness on palpation of long bones, hepatosplenomegaly, and nodes, and the spleen tip was palpable. Laboratory studies
generalized lymphadenopathy. Petechial hemorrhages are showed hemoglobin, 10.1 g/dL; hematocrit, 30.5%; MCV, 90
present on the skin. Laboratory studies show hemoglobin, μm3; platelet count, 89,000/mm3; and WBC count, 31,300/
8.8 g/dL; hematocrit, 26.5%; platelet count, 34,700/mm3; and mm3. From the peripheral blood smear shown in the figure,
WBC count, 14,800/mm3. A bone marrow biopsy specimen which of the following is the most likely diagnosis?
shows 100% cellularity, with almost complete replacement Acute lymphoblastic leukemia
A
by a population of large cells with scant cytoplasm lacking Chronic lymphocytic leukemia
B
granules, delicate nuclear chromatin, and rare nucleoli. His Infectious mononucleosis
C
oncologist is confident that chemotherapy will induce a com- Iron deficiency anemia
D
plete remission. Which of the following combinations of phe- Leukemoid reaction
E
notypic and karyotypic markers is most likely to be present in
marrow cells from this boy? 21 A 37-year-old man infected with HIV for the past 10 years
Early pre-B CD19+ hyperdiploidy
A is admitted to the hospital with abdominal pain of 3 days’ du-
Early pre-B CD20+ t(9;22)
B ration. Physical examination shows abdominal distention and
Pre-B CD5+ normal karyotype
C absent bowel sounds. An abdominal CT scan shows a mass
Pre-B CD23+ 11q deletion
D lesion involving the ileum. He undergoes surgery to remove
T cell CD2+ numerous blasts
E an area of bowel obstruction in the ileum. Gross examination
T cell CD3+ MLL gene translocation
F of the specimen shows a firm, white mass, 10 cm long and 3
cm at its greatest depth. The mass has infiltrated through the
19 A 66-year-old man has noted an increasing number and wall of the ileum. Histologic studies show a mitotically active
size of lumps over his body in the past 5 months. On exami- population of CD19+ lymphoid cells with prominent nuclei
nation, there is firm, nontender inguinal, axillary, and cervi- and nucleoli. Molecular analysis is most likely to show which
cal lymphadenopathy. A biopsy specimen of a cervical node of the following viral genomes in the lymphoid cells?
shows a histologic pattern of nodular aggregates of small, Cytomegalovirus
A
cleaved lymphoid cells and larger cells with open nuclear chro- Epstein-Barr virus
B
matin, several nucleoli, and moderate amounts of cytoplasm. HIV
C
A bone marrow biopsy specimen shows lymphoid aggregates Human herpesvirus 8
D
of similar cells with surface immunoglobulins that are CD10+, Human T-cell lymphotropic virus type 1
E
but CD5−. Karyotyping of these lymphoid cells indicates the
presence of t(14;18). What is the most likely diagnosis?
A Acute lymphadenitis
B Hodgkin lymphoma, nodular sclerosis type
C Follicular lymphoma
D Mantle cell lymphoma
E Toxoplasmosis
  
 C H A P T E R 1 3   Hematopathology of White Blood Cells 187

22 A 12-year-old boy has had increasing abdominal disten- his face. There is no lymphadenopathy or splenomegaly, and
tion and pain for the past 3 days. Physical examination of his he is afebrile. A biopsy of the mass is performed and micro-
abdomen shows lower abdominal tenderness with tympany scopic examination shows intermediate-sized lymphocytes
and reduced bowel sounds. An abdominal CT scan shows a with a high mitotic rate. A chromosome analysis shows a
7-cm mass involving the region of the ileocecal valve. Surgery 46,XY,t(8;14) karyotype in these cells. The hemoglobin concen-
is performed and the resected mass microscopically shows tration is 13.2 g/dL, platelet count is 272,000/mm3, and WBC
sheets of intermediate-sized lymphoid cells, with nuclei hav- count is 5820/mm3. Infection with which of the following vi-
ing coarse chromatin, several nucleoli, and many mitotic figures. ruses is most likely to be causally related to the development
A bone marrow biopsy sample is negative for this cell popu- of these findings?
lation. Cytogenetic analysis of the cells from the mass shows A Cytomegalovirus
a t(8;14) karyotype. Flow cytometric analysis reveals 40% of B Epstein-Barr virus
the cells are in S phase. The tumor shrinks dramatically after C Hepatitis B virus
a course of chemotherapy. Which of the following is the most D HIV
likely diagnosis? E Human papillomavirus
Acute lymphoblastic leukemia/lymphoma
A F Respiratory syncytial virus
Burkitt lymphoma
B   
Diffuse large B-cell lymphoma
C
Follicular lymphoma
D
Plasmacytoma
E

23 A 55-year-old man felt a lump near his shoulder 1 week

ago. On physical examination, there is an enlarged, nontender,
supraclavicular lymph node and enlargement of the Waldeyer
ring of oropharyngeal lymphoid tissue. There is no hepato-
splenomegaly. CBC is normal except for findings of mild ane-
mia. A lymph node biopsy specimen shows replacement by a
monomorphous population of lymphoid cells that are twice the
size of normal lymphocytes, with enlarged nuclei and promi-
nent nucleoli. Immunohistochemical staining and flow cytom-
etry of the node indicates that most lymphoid cells are CD19+,
CD10+, CD3−, CD15−, and terminal deoxynucleotidyl transfer-
ase negative (TdT−). A BCL6 gene mutation is present. Which of
the following is the most likely diagnosis?
Acute lymphoblastic lymphoma
A
Chronic lymphadenitis
B
Diffuse large B-cell lymphoma
C
Hodgkin lymphoma
D
Small lymphocytic lymphoma
E

24 A 62-year-old man has experienced vague abdominal

discomfort accompanied by bloating and diarrhea for the past 26 A 61-year-old man reports back pain for 5 months. He
6 months. On physical examination, there is a midabdominal has recently developed a cough that is productive of yellow
firm mass. The stool is positive for occult blood. An abdominal sputum. On physical examination, he is febrile, and diffuse
CT scan shows an 11 × 4 cm mass involving the wall of the rales are heard on auscultation of the lungs. He has no lymph-
distal ileum and adjacent mesentery. A laparotomy is per- adenopathy or splenomegaly. Laboratory studies include a
formed, and the mass is removed. Microscopically, the mass is sputum culture growing Streptococcus pneumoniae. The serum
composed of sheets of large lymphoid cells with large nuclei, creatinine level is 3.7 mg/dL, and the urea nitrogen level is
prominent nucleoli, and frequent mitotic figures. The neoplastic 35 mg/dL. The figure shows a skull radiograph. A bone mar-
cells mark with CD19+ and CD20+ and have the BCL6 gene row biopsy specimen from this man is most likely to show
rearrangement. Which of the following prognostic features is increased numbers of which of the following?
most applicable to this case? Myeloblasts
A
Aggressive, can be cured by chemotherapy
A Small mature lymphocytes
B
Aggressive, often spreads to liver, spleen, and marrow
B Plasma cells
C
Aggressive, often transforms to acute leukemia
C Reed-Sternberg cells
D
Indolent, can be cured by chemotherapy
D Non-necrotizing granulomas
E
Indolent, often undergoes spontaneous remission
E
Indolent, survival of 7 to 9 years without treatment
F

25 A 9-year-old boy living in Uganda has had increasing

pain and swelling on the right side of his face over the past 8
months. On physical examination, there is a large, nontender
mass involving the mandible, which deforms the right side of
188 U N I T I I   Diseases of Organ Systems

27 A 67-year-old man has had increasing weakness, fatigue,

and weight loss over the past 5 months. He now has decreas- 6
ing vision in both eyes and has headaches and dizziness. His
hands are sensitive to cold. On physical examination, he has
generalized lymphadenopathy and hepatosplenomegaly. 5
Laboratory studies indicate a serum protein level of 15.5 g/dL
and albumin concentration of 3.2 g/dL. A bone marrow biopsy
is performed, and microscopic examination of the specimen 4
shows infiltration by numerous small plasmacytoid lymphoid
cells with Russell bodies in the cytoplasm. Which of the following

g/dL
additional laboratory findings is most likely to be reported for 3
this patient?
A Bence Jones proteinuria
B Hypercalcemia 2
C Karyotype with t(14;18) translocation
D Monoclonal IgM spike in serum
E WBC count of 255,000/mm3 1
  

AIb α1 α2 β γ

29 A 48-year-old man has a routine health maintenance

examination. He has no concerns other than worrying about get-
ting older and having cancer. Physical examination shows that
he is afebrile and normotensive. There is no hepatosplenomegaly
or lymphadenopathy. Laboratory studies show a total serum
protein level of 7.4 g/dL and albumin level of 3.9 g/dL. Serum
calcium and phosphorus levels are normal. Urinalysis shows
no Bence Jones proteinuria. Hemoglobin is 13.6 g/dL, platelet
count is 301,500/mm3, and WBC count is 6630/mm3. The results
of the serum protein electrophoresis are shown in the figure. A
bone marrow biopsy specimen shows normal cellularity with
maturation of all cell lines. Plasma cells constitute about 4% of
28 A 69-year-old woman complains of increasing back pain the marrow. The results of a bone scan are normal, and there are
for 1 month. On physical examination, there is tenderness over no areas of increased uptake. What is the most likely diagnosis?
the lower back, but no kyphosis or scoliosis. A radiograph of A 
Heavy chain disease with lymphoplasmacytic
the spine shows a partial collapse of T10 and multiple 0.5- to lymphoma
1.5-cm lytic lesions with a rounded soap bubble appearance in Monoclonal gammopathy of undetermined
B 
the thoracic and lumbar vertebrae. A bone marrow biopsy is significance
performed, and a smear of the aspirate is shown in the figure. C Multiple myeloma with IgD immunophenotype
Which of the following laboratory findings is most likely to be D Reactive systemic amyloidosis
seen in this patient? E Solitary plasmacytoma of the lung
A Bence Jones proteins in the urine Waldenström macroglobulinemia with
F 
B Decreased serum alkaline phosphatase level hyperviscosity
C Hypogammaglobulinemia
D Platelet count of 750,000/mm3 30 A 62-year-old man has had fever and a 4-kg weight loss
E t(9;22) in the karyotype of marrow cells over the past 6 months. On physical examination, his temperature
F WBC count of 394,000/mm3 is 38.6° C. He has generalized nontender lymphadenopathy, and
   the spleen tip is palpable. Laboratory studies show hemoglobin,
10.1 g/dL; hematocrit, 30.3%; platelet count, 140,000/mm3; and
WBC count, 24,500/mm3 with 10% segmented neutrophils, 1%
bands, 86% lymphocytes, and 3% monocytes. A cervical lymph
node biopsy specimen microscopically shows a nodular pattern
of small lymphoid cells. A bone marrow biopsy specimen shows
infiltrates of similar small cells having surface immunoglobulins
that are CD5+, but CD10−. Cytogenetic analysis indicates t(11;14)
in these cells. What is the most likely diagnosis?
Acute lymphoblastic lymphoma
A
Burkitt lymphoma
B
Follicular lymphoma
C
Mantle cell lymphoma
D
Small lymphocytic lymphoma
E
 C H A P T E R 1 3   Hematopathology of White Blood Cells 189

31 A 54-year-old woman has experienced nausea with venules and infiltrate sinuses. The patient goes into remission
vomiting and early satiety for the past 7 months. On physical after chemotherapy. Which of the following markers is most
examination, she is afebrile and has no lymphadenopathy or likely to be positive in the tumor cells?
hepatosplenomegaly. CBC shows hemoglobin, 12.9 g/dL; he- ALK protein
A
matocrit, 41.9%; platelet count, 263,000/mm3; and WBC count, CD10 antigen
B
8430/mm3. An upper gastrointestinal endoscopy shows loss c-KIT proto-oncogene
C
of the rugal folds of the stomach over a 4 × 8 cm area of the IL-2 receptor
D
fundus. Gastric biopsy specimens reveal the presence of p24 antigen
E
Helicobacter pylori organisms in the mucus overlying superfi-
cial epithelial cells. There are extensive mucosal and submu- 34 A 51-year-old man has skin on his face, neck, and trunk
cosal monomorphous infiltrates of small lymphocytes, which that has become scaly red, with intense itching, and a 3-kg
are CD19+ and CD20+, but CD3−. After treatment of the H. py- weight loss over the past 2 months. On physical examination,
lori infection, her condition improves. What is the most likely his temperature is 37.6° C, and he has a generalized exfoliative
diagnosis? erythroderma. Generalized nontender lymphadenopathy is
A Acute lymphoblastic leukemia present. Laboratory studies show hemoglobin, 12.9 g/dL; he-
B Chronic lymphocytic leukemia matocrit, 42%; platelet count, 231,000/mm3; and WBC count,
C Diffuse large B-cell lymphoma 7940/mm3 with 57% segmented neutrophils, 3% bands, 26%
D Follicular lymphoma lymphocytes, 5% monocytes, and 9% eosinophils. A skin biopsy
E Hodgkin lymphoma, mixed cellularity type specimen microscopically shows the presence of lymphoid
F MALT (marginal zone) lymphoma cells in the upper dermis and epidermis. These cells have cere-
   briform nuclei with marked infolding of nuclear membranes.
Similar cells are seen on the peripheral blood smear. Which
combination of the following phenotypic markers is most likely
to be expressed on his abnormal lymphocytes?
CD3+, CD4+
A
CD5+, CD56+
B
CD10+, CD19+
C
CD13+, CD33+
D
CD19+, sIg+
E

35 A 58-year-old man from Nagasaki, Japan, has noted an

increasing number of skin lesions for the past 8 months. On
examination, there are scaling red-brown patches on all skin
surfaces. He also has generalized lymphadenopathy and hepato-
splenomegaly. Laboratory studies show hemoglobin, 9.7 g/dL;
hematocrit, 31%; MCV, 89 μm3; platelet count, 177,000/mm3;
and WBC count, 18,940/mm3 with differential count of 35%
32 A 41-year-old man has experienced several bouts of pneu- segmented neutrophils, 2% band neutrophils, 58% lympho-
monia over the past year. He now complains of vague abdominal cytes, and 5% monocytes. His serum calcium is 11.5 mg/dL.
pain and a dragging sensation. Physical examination shows Examination of his peripheral blood smear shows multilobated
marked splenomegaly. CBC shows hemoglobin, 8.2 g/dL; he- “cloverleaf” cells. Which of the following infectious agents
matocrit, 24.6%; MCV, 90 μm3; platelet count, 63,000/mm3; and most likely caused his illness?
WBC count, 2400/mm3. The peripheral blood smear shows A
Bartonella henselae
many small leukocytes with the features shown in the figure. A Cytomegalovirus (CMV)
B
chest radiograph shows patchy infiltrates, and a culture of spu- Epstein-Barr virus (EBV)
C
tum grows Mycobacterium kansasii. Which of the following labo- D
Helicobacter pylori
ratory findings is most characteristic of this disorder? HIV
E
Cytoplasmic Auer rods in myeloid cells
A HTLV-1
F
CD20 and CD11c positive lymphocytes
B
Monoclonal IgM in serum
C 36 A 26-year-old man has noted lumps in his neck that have
t(9:22) translocation in stem cells
D been enlarging for the past 6 months. On physical examination,
Cytoplasmic toxic granulations in neutrophils
E he has a group of enlarged, nontender right cervical lymph
nodes. A biopsy of one of the lymph nodes microscopically
33 A 29-year-old, previously healthy man has had an en- shows macrophages, lymphocytes, neutrophils, eosinophils,
larging nodular area on his arm for the past 8 months. On physi- and a few plasma cells. There are scattered CD15+ large cells
cal examination, there is an ulcerated, reddish violet, 3 × 7 cm with multiple nuclei or a single nucleus with multiple nuclear
lesion on his right forearm and nontender right axillary and lobes, each with a large inclusion-like nucleolus. What is the most
left inguinal lymphadenopathy. A chest radiograph shows likely cell of origin with infectious agent for these large cells?
a 4-cm nodular left pleural mass. An abdominal CT scan B lymphocyte, Epstein-Barr virus
A
shows a 5-cm right retroperitoneal mass. Biopsy of an ingui- CD4+ cell, human T lymphotropic virus
B
nal node is performed, and microscopic examination shows Endothelial cell, Kaposi sarcoma herpesvirus
C
large cells, some of which contain horseshoe-shaped nuclei Macrophage, human immunodeficiency virus
D
and voluminous cytoplasm. The tumor cells cluster around NK cell, cytomegalovirus
E
190 U N I T I I   Diseases of Organ Systems

37 A 34-year-old woman reports having generalized fatigue

and night sweats for 3 months. Physical examination shows non-
tender right cervical lymphadenopathy. Biopsy of one lymph
node is performed, and microscopic examination shows a pat-
tern of thick bands of fibrous connective tissue with intervening
lymphocytes, plasma cells, eosinophils, macrophages, and oc-
casional Reed-Sternberg cells. An abdominal CT scan and bone
marrow biopsy specimen show no abnormalities. Which of the
following is the most likely subtype of this patient’s disease?
Lymphocyte depletion
A
Lymphocyte predominance
B
Lymphocyte rich
C
Mixed cellularity
D
Nodular sclerosis
E

38 A 74-year-old man has experienced recurrent fevers and

a 6-kg weight loss over the past 5 months. On physical exami- 41 A 29-year-old woman has experienced fatigue, fever,
nation, his temperature is 37.5° C, and he has splenomegaly. night sweats, and painless lumps in the right side of her neck
An abdominal CT scan shows mesenteric lymphadenopathy. for the past 3 months. On physical examination, her temperature
A lymph node biopsy specimen shows effacement of the nod- is 37.5° C. She has right cervical nontender lymphadenopathy.
al architecture by a population of small lymphocytes, plasma One of the lymph nodes is biopsied, and a histologic finding
cells, eosinophils, and macrophages. Which of the following is shown at high power in the figure. A molecular analysis of
additional cell types, which stains positively for CD15 and large cells exemplified by the cell at the center is most likely to
CD30, is most likely to be found in this disease? reveal which of the following genetic abnormalities?
Epithelioid cell
A Clonal rearrangement of T-cell receptor genes
A
Immunoblast
B Clonal rearrangement of immunoglobulin genes
B
Mast cell
C Integration of the HTLV-1 genome
C
Myeloblast
D Integration of the human herpesvirus 8 genome
D
Reed-Sternberg cell
E Polyclonal rearrangement of T-cell receptor genes
E
Polyclonal rearrangement of immunoglobulin genes
F
39 A 63-year-old man has noticed a lump in his neck for 2
months. Examination reveals a group of three discrete non- 42 A 33-year-old man has experienced multiple nosebleeds
tender right posterior cervical lymph nodes, and a mass of along with bleeding gums for the past month. On examination,
enlarged right axillary lymph nodes. Chest and abdominal CT his temperature is 37.3° C. He has multiple cutaneous ecchy-
scans show mediastinal lymphadenopathy and hepatospleno- moses. Laboratory studies show hemoglobin, 8.5 g/dL; hema-
megaly. Microscopic examination of a cervical lymph node tocrit, 25.7%; platelet count, 13,000/mm3; and WBC count,
biopsy reveals abundant large CD15+ and CD30+ binucleate 52,100/mm3 with 5% segmented neutrophils, 5% bands, 2%
cells with prominent acidophilic nucleoli, scattered within a myelocytes, 83% blasts, 3% lymphocytes, and 2% monocytes.
sparse lymphocytic infiltrate. What is molecular analysis of Examination of his peripheral blood smear shows the blasts
this lesion most likely to reveal? have delicate nuclear chromatin along with fine cytoplasmic
Clonal EBV integration in the large cells
A azurophilic granules. These blasts are CD33+. Which of the
BCL6 gene rearrangements in the large cells
B following morphologic findings is most likely to be present on
Deletions of 5q in all the cells
C his peripheral blood smear?
Helicobacter pylori infection in all the cells
D A Auer rods
JAK2 gene mutations in the lymphocytes
E B Döhle bodies
C Hairy projections
40 A 22-year-old woman has experienced increasing dyspnea D Heinz bodies
for the past 2 months. On physical examination, she is afebrile E Sickle cells
and normotensive. Inspiratory wheezes are noted on ausculta- F Toxic granulations
tion of the chest. A chest CT scan shows an 8 × 10 cm posterior   
mediastinal mass that impinges on the trachea and esophagus.
A mediastinoscopy is performed, and a biopsy of the mass
microscopically shows scattered large multinucleated cells,
with prominent nucleoli that mark with CD15, and lympho-
cytes and macrophages separated by dense collagenous
bands. Which of the following cells is most likely to be seen
microscopically in this biopsy specimen?
A Atypical lymphocytes
B Hairy cells
C Langerhans cells
D Lacunar cells
E Lymphoblasts
F Myeloblasts