A Rare Case of Chronic Lymphocytic Leukemia Mimicking as Carcinoma Lung

ABSTRACT

Introduction: Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder with clonal proliferation of functionally incompetent mature B lymphocytes, defined by an absolute lymphocyte count>5 9 109/ml malignant cells in the blood. The disorder is more common in men. In most of the cases, it is asymptomatic and diagnosed during routine blood investigations while getting evaluated for some other disease. However, patients need treatment once they are symptomatic with painless enlarged, bulky lymphnodes, anemia or thrombocytopenia. Case report We report a case of 67 year female, with Type-2DMand HTN, who presented with difficulty in breathing to the emergency during the first wave of Covid -19 pandemic. Chest X-ray revealed left mid zone opacity suggestive of a lung mass. CT Thorax done showed multiple mildly enlarged mediastinal lymph nodes, with lobulated heterogeneously enhancing mass in the prevascular compartment of anterior mediastinum compressing left upper lobar bronchus. USG guided core needle biopsy of left upper lobe mass was done and pleural fluid was analysed, which was suggestive of a lymphoproliferative neoplasm. Then CBC was advised which demonstrated lymphocytosis. Flow cytometry and IHC confirmed the diagnosis mature B-cell neoplasm Chronic Lymphocytic Leukemia (CLL). Discussion(s) Pulmonary manifestation of CLL include, hilar and mediastinal lymphadenopathy. Lung masses are a rare presentation. Richter's transformation is a unique complication of CLL. However, patients with CLL also have an increased risk of secondary malignancy most commonly Kaposi sarcoma, malignant melanoma and carcinoma lung. Our case is unique,as there were no features of Richter transformation that is weight loss, fever, night sweats, muscle wasting and increased hepatosplenomegaly or lymphadenopathy. She was evaluated for respiratory distress and diagnosed on Lung mass biopsy as atypical lymphoid cell infiltration and not as lung carcinoma or transformation to high grade lymphoma. Conclusion(s) Clinicians should be aware that though chronic lymphocytic leukemia is diagnosed incidentally on routine blood investigations, atypical presentation must be kept in mind. A simple CBC and a peripheral smear examination gives a clue to the diagnosis at the earliest.