A patient with CLL and a dry cough

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.

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.