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Immunophenotyping of peripheral blood and karyotype analysis were performed as the next steps in the diagnostic workup.

• Immunophenotyping of the peripheral blood by flow cytometry: showed 80% abnormal B cells that were positive for pan B-cell markers (CD19, cytoplasmic CD79a, CD20, and cytoplasmic CD22), CD45 (bright), human leukocyte antigen DR isotype (HLA-DR), cytoplasmic CD79b, CD10 (dim), and CD200. They were negative for CD3, CD5, CD7, CD34, TdT, CD103, CD38, surface CD22, surface CD79b, FMC7, and CD30.
• Karyotype analysis: Examination of 20 metaphases showed a complex karyotype with some missing chromosomes, deletions, and translocations: 42,X,-X,del(1)(q36), t(4;17)(q27;q25),-8, t(12;21)(q24;q22),-14,-18, and del(19)t(9;19)(q11;p11)(20).

These findings, along with the clinical and radiologic data, suggested an unusual immunophenotype that posed a diagnostic challenge.

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