A 72-year-old woman presents with progressive, bilateral hearing loss for 1 year. She was treated for bilateral otitis media earlier, which included placement of myringotomy tubes. However, her symptoms have not improved. Close questioning reveals a history of chronic fatigue and dyspnea on exertion for more than 2 years, which she attributed to old age. Her medical, surgical and family histories are unremarkable and she is not on any medications currently.

Her complete blood count reveals a leukocyte count of 85,600 with 80% lymphocytes, a hemoglobin level of 10.9 g/dL, and a platelet count of 130,000/mm3. A peripheral blood film reveals lymphocytosis, thrombocytopenia and smudge cells.