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Pulmonary Parenchymal Disease in a Patient With Chronic Lymphocytic Leukemia FREE TO VIEW

Sean Roark*, MD; Christopher King, MD; John Sherner, MD
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Walter Reed National Military Medical Center, North Bethesda, MD

Chest. 2012;142(4_MeetingAbstracts):563A. doi:10.1378/chest.1389860
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SESSION TYPE: Cancer Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Chronic Lymphocytic Leukemia (CLL) is a common haemotologic malignancy which can affect multiple organ systems. Pulmonary complications are most commonly infectious in nature, but here we present a case of parenchymal leukemic infiltratation.

CASE PRESENTATION: An 80-year-old man with history of chronic lymphocytic leukemia (CLL) diagnosed in 1983 presented to our institution with complaints of progressive cough, weight loss, and intermittent fever for several months. Prior to his current presentation, his CLL was indolent, not requiring specific treatment. Six months before his respiratory illness, he developed autoimmune hemolytic anemia requiring three months of steroids. Following completion of a steroid taper, he developed progressive respiratory complaints. His chest radiograph showed persistent right lung infiltrate, for which he had received multiple courses of antibiotics by his primary care physician for presumed pneumonia over the subsequent two months without response. At the time of presentation, the patient’s white blood cell count was 5.8 X 103/mcL with 51.4% lymphocytes. A chest CT was obtained and showed right hilar and subcarinal lymphadenopathy as well as an ill-defined right hilar soft tissue mass with airway narrowing. He underwent a fiberoptic bronchoscopy which confirmed narrowing and erythema at the right middle lobe takeoff. Cytologic brushing, needle aspirations, and endobronchial biopsy were taken at this site which showed mucosal involvement with homogenous, mature, CD 20, CD5, and CD23 positive lymphocytes consistent with small lymphocytic lymphoma (SLL). Respiratory cultures were negative for infectious etiologies to include fungal organisms, acid-fast bacilli and Pneumocystis jiroveci. A PET scan revealed hypermetabolism in the right hilar mass and airspace disease. The patient was diagnosed with pulmonary SLL and referred to the oncology service. He was treated with radiation to the right hilar mass.

DISCUSSION: CLL is a common adult hematological malignancy accounting for approximately 30% of leukemias. The majority of pulmonary disease seen in CLL is caused by infectious complications. Pulmonary parenchymal involvement is much less common and typically occurs in patients with advanced disease. Rarely pulmonary involvement may be the sole or major manifestation of CLL. We present a case of a persistent pulmonary infiltrate in indolent CLL with biopsy proven pulmonary involvement as the major manifestation of disease.

CONCLUSIONS: This case emphasizes that clinicians should maintain suspicion for direct involvement of disease in leukemic patients presenting with persistent respiratory complaints and imaging abnormalities.

1) Ahmed, S, et al. “Pulmonary Complications in Chronic Lymphocytic Leukemia,” Cancer. 1Nov 2003; Vol 98(9). 1912-1917

2) Berkman N, Polliack A, et al. Pulmonary involvement as the major manifestation of chronic lymphocytic leukemia. Leuk Lymphoma. 1992; 8(6): 495-9.

DISCLOSURE: The following authors have nothing to disclose: Sean Roark, Christopher King, John Sherner

No Product/Research Disclosure Information

Walter Reed National Military Medical Center, North Bethesda, MD




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