Flowers beyond the Leukemia Garden: A Floral Surprise in a Case of Pancytopenia

A 38-year-old man presented with 2 weeks of fever, weakness, and drowsiness. There was no family history or significant prior history. Physical examination showed pallor. No organomegaly was identified. A complete blood examination revealed reduced hemoglobin (10.3 g/dL) and total leukocyte count (2.8 × 109/L), with a differential cell count of neutrophils (68%), lymphocytes (26%), eosinophils (2%), and monocytes (4%). The platelet count was also reduced (60 × 109/L). Peripheral blood smear showed normocytic normochromic anemia and few flower-like cells with petal-shaped nuclei [Figure 1].Figure 1: A peripheral blood smear displaying normocytic normochromic anemia and flower like cells with petal shaped nuclei (Leishman stain, ×40)Immunoglobulin M (IgM) and IgG dengue antibodies were positive, whereas nonstructural protein 1 was negative. It confirms the diagnosis of dengue fever convalescence. Serum urea 30 mg/dL, creatinine 0.66 mg/dL, bilirubin 1.29 mg/dL, aspartate transaminase 40 IU/L, and alanine transaminase 22 mg/dL were normal. Random glucose was 75 mg/dL. HBsAg, anti-hepatitis C virus, and human immunodeficiency virus serology were negative. Flower-shaped cells in a peripheral blood smear usually indicate mature, atypical lymphocytes with petal-shaped nuclei. They are commonly associated with HTLV-1-associated adult T-cell leukemia/lymphoma.[1] Flower-like plasma cells have been found in plasma cell leukemia. However, hepatitis B and reactive causes, such as the dermatitis and convalescent phase of viral infections like dengue fever, may also exhibit flower-like cells rarely, as demonstrated in the current case.[2-5] CD20 or CD138 immunocytochemistry can confirm these cells were flower-like plasma cells or lymphocytes.[5] This case reemphasizes the rare occurrence of flower-like cells in reactive conditions such as in the recovery phase of dengue fever. The morphology serves as a diagnostic clue, demanding correlation with clinical context and to exclude hematologic malignancies such as Adult T-Cell Leukemia/Lymphoma (ATLL) or plasma cell leukemia. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.