Endgames Picture Quiz

A patient with CLL and a dry cough

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c3051 (Published 30 June 2010) Cite this as: BMJ 2010;340:c3051
  1. Dimitris A Tsitsikas, specialist registrar in haematology1,
  2. Sarah Vinicombe, consultant radiologist2,
  3. Michael Sheaff, consultant histopathologist3,
  4. Stephen Ellis, consultant radiologist2,
  5. Hasan Rizvi, consultant histopathologist3,
  6. Rohini Manuel, consultant microbiologist4,
  7. Samir G Agrawal, consultant haematologist1
  1. 1Department of Haematological Oncology, Barts and the London NHS Trust, London EC1A 7BE
  2. 2Department of Radiology, Barts and the London NHS Trust
  3. 3Department of Histopathology, Barts and the London NHS Trust
  4. 4Department of Microbiology, Barts and the London NHS Trust
  1. Correspondence to: D A Tsitsikas dimitristsitsikas{at}hotmail.com

    A 51 year old man was diagnosed with stage C chronic lymphocytic leukaemia (CLL) after he was found incidentally to have marked lymphocytosis on a routine blood test with characteristic morphological and immunophenotypic features. He had massive splenomegaly which was confirmed on computed tomography, lymphadenopathy both sides of the diaphragm, mild anaemia, thrombocytopenia, and neutropenia, but he was entirely asymptomatic and otherwise well. After he had received the necessary vaccinations and started penicillin prophylaxis, he underwent splenectomy, but chemotherapy was deferred for several weeks at his request. Of note, he had travelled to North America and South America in recent years.

    Restaging computed tomography scans before he started chemotherapy showed newly developed bilateral lung nodules (fig 1). He underwent extensive investigations, and infective causes such as tuberculosis, mycoplasma, legionella, and viral pneumonia were excluded. Throughout this time, apart from an intermittent dry cough, he remained entirely well.

    Fig 1 Computed tomography of the thorax

    Repeat computed tomography was undertaken six weeks later (fig 2). Because no cause had been found for lung nodules, he underwent percutaneous lung biopsy, and when that failed to yield an adequate sample, open lung biopsy. Histological examination of the sample showed circumscribed foci of necrosis associated with colonies of fungal spores that displayed birefringence and occasional budding.

    Fig 2 Repeat computed tomography scan six weeks later

    Questions

    • 1 What do the computed tomograms of the chest show?

    • 2 What is the most likely underlying diagnosis?

    • 3 How is this condition treated?

    • 4 What is the likely connection between this diagnosis and the patient’s CLL?

    Answers

    1 What does the computed tomogram of the chest show?

    Short answer

    The computed tomography scans of the thorax show multiple, bilateral, well defined pulmonary nodules that have progressed over the six week interval (figs 3 and 4).

    Fig 3 Multiple bilateral well …

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