Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II |

Chronic Lymphocytic Leukemia Presenting as a Pulmonary Cavity and Endobronchial Nodular Mucosal Lesion FREE TO VIEW

Andrew Pham, MD; Steven Wong, MD
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Scripps Mercy, San Diego, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1091A. doi:10.1016/j.chest.2016.08.1198
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Over one third of chronic lymphocytic leukemia (CLL) patients have pulmonary involvement. Pathologic pulmonary leukemic infiltration occurs in roughly 18% of cases and can present with different radiographic features. Other pulmonary manifestations include hilar and mediastinal lymphadenopathy, pleural effusion, and rarely endobronchial involvement. We present a rare case of a pulmonary cavity and endobronchial nodular lesions leading to the diagnosis of CLL.

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.

DISCUSSION: Chronic lymphocytic leukemia is the most common leukemia in the western world, but pulmonary infiltration occurs in only a small subset of these patients. Radiographic findings of pulmonary involvement include interstitial thickening, parenchymal nodules, and centrilobular tree-in-bud opacities. Atelectasis and airway obstruction can be noted if an endobronchial involvement is present. While endobronchial involvement is uncommon in non-Hodgkin’s lymphoma, it is particularly rare in CLL. Severe bronchial narrowing from friable edematous mucosa and formation of intrabronchial plaques have been reported. To our knowledge, CLL causing pulmonary cavity and focal nodular-appearing endobronchial mucosal lesions has not been previously reported.

CONCLUSIONS: Clinicians should be aware that chronic lymphocytic leukemia can have multiple pulmonary radiographic and clinical features, including rare findings of lung cavity and focal endobronchial nodular mucosal lesions.

Reference #1: L. E. Heyneman, T. Johkoh, S. Ward, O. Honda, S. Yoshida, N. L. Müller. Pulmonary leukemic infiltrates: high-resolution CT findings in 10 patients. AJR Am J Roentgenol. 2000 February; 174(2): 517-521

DISCLOSURE: The following authors have nothing to disclose: Andrew Pham, Steven Wong

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