SESSION TITLE: Miscellaneous Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: We present a patient with chronic lymphocytic leukemia which resulted in diffuse alveolar hemorrhage, likely related to leukostasis.
CASE PRESENTATION: A 62 year-old man with indolent chronic lymphocytic leukemia (CLL) never requiring treatment was admitted from Oncology clinic with significantly increased leukocytosis to 174,000/mm3, as well as thrombocytopenia to 10,000/mm3, and severe anemia. A bone marrow biopsy was performed, confirming CLL without blast crisis, and diffuse adenopathy was newly noted, suggesting Richter’s transformation. The patient left against advice, but presented one week later at a different hospital with progressive dyspnea, where he was found to have diffuse bilateral pulmonary infiltrates and hypoxemia requiring 100% FiO2. He was treated with broad antibiotics and steroids for 2 days prior to transfer to our ICU, where he was solely treated with prednisone 40 mg PO BID and empiric Bactrim at Pneumocystis dosing, as well as platelet transfusions to keep levels above 50,000/mm3. Over the next several days, he had dramatic improvement in radiographic infiltrates and need for supplemental oxygen. His leukocyte count decreased below 100,00/mm3 without evidence of tumor lysis. On day 5, bronchoscopy with serial lavage demonstrated findings consistent with diffuse alveolar hemorrhage. Bacterial, fungal, viral, and AFB cultures were negative. Silver stain and cytology were also negative. He was discharged on room air with plans for chemotherapy.
DISCUSSION: This case demonstrates an episode of diffuse alveolar hemorrhage (DAH) related to chronic lymphocytic leukemia, an association that is not previously reported. DAH results from significantly increased permeability of the alveolar-capillary interface such that red blood cells extravasate into the alveolar space. Hematological malignancy is most often implicated in DAH in the setting of stem cell transplant, but case series have also reported DAH in association with leukemia. Establishing a pathogenesis is difficult, but known pulmonary manifestations of leukemia - such as leukemic infiltrates, lysis, and leukostasis - are likely to play a role. Leukostasis is most suspect in this case, as it occurs when leukocyte counts are above 100,000/mm3 or with a rapid increase. While uncommon, leukostasis has been reported in CLL.
CONCLUSIONS: In this patient, diffuse alveolar hemorrhage was observed as a likely manifestation of leukostasis from chronic lymphocytic leukemia.
Reference #1: Hildebrand FL, Rosenow EC, Habermann TM, Tazelaar HD. Pulmonary complications of leukemia. CHEST. 1990;98(5):1233-1239.
Reference #2: Vincent F. Leukostasis, Infiltration and Pulmonary Lysis Syndrome Are the Three Patterns of Leukemic Pulmonary Infiltrates. In: Pulmonary Involvement in Patients with Hematological Malignancies. Berlin, Heidelberg: Springer Berlin Heidelberg; 2010:509-520.
Reference #3: Ahmed S, Siddiqui AK, Rossoff L, Sison CP, Rai KR. Pulmonary complications in chronic lymphocytic leukemia. Cancer. 2003;98(9):1912-1917.
DISCLOSURE: The following authors have nothing to disclose: Jeremy Orr, Laura Crotty-Alexander, Judd Landsberg
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