Digital images of blast cells from the pleural effusion, as presented on the digital analyzer. 

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... Sysmex XE-5000 TM (Sysmex Corporation, Kobe, Japan) hematology analyzer, equipped with the body fluid module, was used as previously described 1 to obtain the patient's cell count, and to achieve white blood cell differ- entiation into mononuclear (MN) and polymorphonuclear cells; we obtained a cell count of 14,000 cells/µL (90% MN cells, and 10% polymorphonuclear cells). Cell cluster spreading from the MN area into the high-fluorescence area was observed ( Figure 2A); this cell cluster had higher forward and side scatter than normal cells ( Figure 2B), meaning that those cells were bigger and more complex. Cytospin preparation (CytoFuge2; IRIS International, Chatsworth, CA, USA) was performed with the pleural fluid using 250-300 µL of the cell suspension (20 cells/µL) to obtain a cell pellet of approximately 5,000 cells. The slides were air-dried and stained with the modified Wright-Giemsa method. Slides were analyzed using the CellaVision ® DM96 (CellaVision AB, Lund, Sweden). 2 Morphological examina- tion (Figure 3) of the pleural fluid revealed a massive infil- tration of immature cells, with large and clefted nuclei; the cytoplasm was basophilic without granules, and was scant in volume, large in size, presenting with fine chromatin and evident nucleoli. To clarify the nature of the immature cells observed in the pleural fluid, flow cytometry analysis was performed. A panel of antibodies including surface CD3 (CD3), cytoplasmic CD3 (CD3Cy), CD7, CD4, CD8, CD2, CD5, cytoplasmic TdT (TdTCy), CD45, and CD1a was used. The analysis was performed using a FACSCanto TM II flow cytometer (BD Biosciences, San Jose, CA, USA). Cytograms (Figure 4) showed that the cells (in red; P1) were CD45+/-, CD3-, CD7++, CD5+, CD2-, CD34+/-, CD1a-, CD3Cy+, TdTCy+, which were immature T-lineage cells. Therefore, a bone marrow aspirate was performed (Figure 5), which showed an infiltration of lymphoblast cells. Flow cytometry analysis on peripheral blood and bone marrow ( Figure 6) were also performed; according to the European Group for the Immunological Classification of Leukemia (EGIL) cri- International Medical Case Reports Journal 2013:6 ...