An unusual case of severe anaemia and lymphocytosis

Observations were heart rate 90 beats/min, blood pressure 110/60 mm Hg, respiratory rate 18 breaths/min, oxygen saturations 98% on room air, and temperature 37°C. Blood test showed haemoglobin 44g/L (reference range 133-167), white blood cell count 125x109 cells/L (3.5-11), lymphocytes 122.4x109 cells/L (1.0-3.0), neutrophils 0.39x109 cells/L (2.0-7.0), platelets 54x109/L (150-410), reticulocytes 1x109/L (25-75), and C reactive protein 114.2 nmol/L (0.76-28.5). Common side effects include infusion reactions and reactivation of latent infections, particularly hepatitis B. Patients must be routinely screened for viral infections before starting treatment. 17 Patients with a poor performance status owing to comorbidities can be treated with less intensive chemotherapy regimens, such as oral chlorambucil or rituximab combined with bendamustine. 14 Patients with TP53 deletions or mutations are defined as having high risk disease and are offered alemtuzumab with steroids because they tend to respond poorly to standard chemotherapy. 6 Alemtuzumab is a humanised monoclonal antibody that targets CD52 positive cells. Because it is highly immunosuppressive, it carries an increased risk of neutropenic sepsis and clinically significant cytopenias.