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Neutropenia With Respiratory Syncytial Virus Infection in Large Granular Lymphocyte (LGL) Leukemia FREE TO VIEW

Ramasubramanian Baalachandran, MD; James Knepler, MD
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University of Arizona, Tucson, AZ

Chest. 2015;148(4_MeetingAbstracts):95A. doi:10.1378/chest.2259704
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SESSION TITLE: Chest Infections I Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Viral infections have been shown to cause autoimmune diseases including autoimmune neutropenia.The etiology of neutropenia in LGL leukemia is unknown, but there is some evidence for autoimmune mechanism. We report a case of T-cell LGL leukemia presenting as neutropenia with Respiratory Syncytial Virus (RSV) infection.

CASE PRESENTATION: A 66 year-old lady, with history of rheumatoid arthritis and asthma, presented with worsening dyspnea, cough, yellow sputum and pleuritic chest pain for 2 weeks. It was associated with fever, chills and myalgia. She had undergone left lower lobectomy of lung for aspergilloma 15 years ago, which had been associated with neutropenia. Physical examination showed fever, tachycardia, tachypnea, hypoxia and bilateral wheeze on auscultation. Laboratory tests revealed leucopenia (700 cells/cu.mm), thrombocytopenia (70,000 cells/cu.mm) and normal hemoglobin (14 g/dl). Absolute neutrophil count was 90 cells/microliter. Oxygen supplementation by nasal cannula and albuterol nebulization were initiated. Nasopharyngeal swab was positive for Respiratory Syncytial virus. Neutropenia was evaluated with bone marrow biopsy, which confirmed T-cell Large granular Lymphocyte Leukemia. Prednisone was started, resulting in clinical improvement over next 3 days. Absolute neutrophil count improved to 550 cells/microliter with steroid therapy for 2 weeks.

DISCUSSION: LGL leukemia is an indolent hematologic disorder with chronic and transient neutropenia as a common presentation. Autoimmunity is suspected to be the cause of cytopenia in LGL leukemia1. Molecular mimicry by viruses has been implicated as a cause of autoimmune diseases. Many antibodies isolated against viral proteins including paramyxoviridae, have shown cross-reactivity with host proteins from uninfected tissues. There are studies showing viral infections as cause of autoimmune neutropenia. Neutropenia was observed during course of viral infections in children, RSV being one of them2. There are case reports of influenza and Human Herpes virus infections causing autoimmune neutropenia1. We did not find any case report of RSV infection and neutropenia.

CONCLUSIONS: We postulate that RSV infection could be the cause of transient worsening of chronic neutropenia in this patient with LGL leukemia. Further research into role of RSV infection in inducing autoimmunity may reveal the cause of neutropenia in LGL leukemia.

Reference #1: Autrel-Moignet A, Lamy T. Autoimmune neutropenia. Presse Med. 2014 Apr;43(4 Pt 2):e105-18. Epub 2014 Mar 27.

Reference #2: Karavanaki K, Polychronopoulou S, Giannaki M, Haliotis F et al. Transient and chronic neutropenias detected in children with different viral and bacterial infections. Acta Paediatr. 2006;95:565-572.

DISCLOSURE: The following authors have nothing to disclose: Ramasubramanian Baalachandran, James Knepler

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