MEDizzy - A 75-year-old man presents to the emergency department

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USMLE I Test Block V

A 75-year-old man presents to the emergency department complaining of a rash. He says he noticed its onset 3 days prior and that it has been worsening since then. His review of systems is notable only for feeling tired lately. He has no known allergies. Physical examination reveals erythematous lesions covering his trunk and extremities that are most severe on his legs and buttocks. He denies pruritus. The lesions do not blanch under pressure. Massive splenomegaly is observed. His WBC count is 80,000/mm³, hemoglobin is 8.8 g/dL, and platelet count is 8000/mm³. The patient’s infectious work-up is negative, but his bone marrow aspirate shows cells resembling mature lymphocytes packing the bone marrow. The patient is admitted to the hospital for further evaluation and supportive care. Which of the following potential therapies is the most appropriate for rapid and long-lasting correction of this patient’s thrombocytopenia?

ExplanationThe correct answer is C. The patient’s condition is most consistent with a diagnosis of chronic lymphocytic leukemia. Although most patients with this disease are diagnosed incidentally or with complaints of fatigue, 10%–20% of patients present with massive splenomegaly and resultant anemia and thrombocytopenia. This patient has symptoms of both, and his physical examination reveals classic petechiae, likely due to the low platelet count. Splenectomy in patients with chronic lymphocytic leukemia induced thrombocytopenia corrects the abnormality in 70%–85% of cases