CASE PRESENTATION: A 74 year-old female presented with dry cough. Chest x-ray demonstrated a right upper lung field opacification, and subsequent CT scan revealed a 2.4 cm right upper lobe (RUL) lung cavity. Other CT scan findings included patchy areas of tree-in-bud nodular infiltrates and bilateral lymphadenopathy in the supraclavicular, axillary and mediastinal regions. She was noted to have emigrated from a tuberculosis-endemic country and therefore was placed in respiratory isolation. Bronchoscopic examination unexpectedly noted multiple small nodular lesions in the larynx, with similar appearing lesions noted focally on left upper lobe (LUL) mucosa. Endobronchial biopsy of the LUL mucosal lesions was performed. Significant bleeding from the mucosal biopsy prevented biopsy of the RUL cavitary lesion, but a bronchoalveolar lavage was performed. Pathology from the LUL endobronchial lesions returned as CLL, while the RUL BAL cytology and microbiology studies were non-diagnostic. Subsequent CT-guided biopsy of the RUL cavity and axillary lymph node, as well as peripheral blood flow cytometry all also demonstrated CLL. Since initial presentation, the patient developed significant B symptoms, ZAP 70 positivity, and a rapid lymphocyte doubling time. Therefore, she is currently under evaluation for treatment with ibrutinib.